Standard Employment Verification Form

X
Employment Verification Form
EMPLOYEE’S NAME:
PLACE OF EMPLOYMENT:
EMPLOYER’S PHONE #:
I authorize the release of this information and give permission to the Child Care Information Services (CCIS) agency to verify all information contained in this form.
Employee’s Signature(s) Date
THE FOLLOWING SECTIONS MUST BE COMPLETED BY THE EMPLOYER.
IS THE ABOVE-MENTIONED EMPLOYEE NEWLY HIRED?
Yes
No
EMPLOYMENT START DATE:
JOB TITLE:
EMPLOYMENT INCOME
HOURLY RATE:
AVERAGE DAILY TIPS: GROSS PAY: NEXT PAY DATE:
( )
$
$ $
FREQUENCY OF PAY:
Weekly
Bi-weekly (26 pays/year)
2x month (24 pays/year)
Monthly
DOES THE EMPLOYEE RECEIVE PAYSTUBS?
Yes
No
EMPLOYMENT SCHEDULE
(Please indicate the days and hours the employee works and indicate whether the hours occur during A.M. or P.M.)
NOTE: If the schedule varies, please give a 4-week sample schedule.
WEEK ONE Dates: from
to
Mon. from
A.M./P.M. to A.M./P.M.
Tues. from A.M./P.M. to A.M./P.M.
Wed. from A.M./P.M. to A.M./P.M.
Thur. from A.M./P.M. to A.M./P.M.
Fri. from A.M./P.M. to A.M./P.M.
Sat. from A.M./P.M. to A.M./P.M.
Sun. from A.M./P.M. to A.M./P.M.
TOTAL # HOURS/WEEK:
WEEK TWO Dates: from
to
Mon. from
A.M./P.M. to A.M./P.M.
Tues. from
A.M./P.M. to A.M./P.M.
Wed. from A.M./P.M. to A.M./P.M.
Thur. from A.M./P.M. to A.M./P.M.
Fri. from A.M./P.M. to A.M./P.M.
Sat. from A.M./P.M. to A.M./P.M.
Sun. from A.M./P.M. to A.M./P.M.
TOTAL # HOURS/WEEK:
WEEK THREE Dates: from
to
Mon. from
A.M./P.M. to A.M./P.M.
Tues. from
A.M./P.M. to A.M./P.M.
Wed. from A.M./P.M. to A.M./P.M.
Thur. from A.M./P.M. to A.M./P.M.
Fri. from A.M./P.M. to A.M./P.M.
Sat. from A.M./P.M. to A.M./P.M.
Sun. from A.M./P.M. to A.M./P.M.
TOTAL # HOURS/WEEK:
WEEK FOUR Dates: from
to
Mon. from
A.M./P.M. to A.M./P.M.
Tues. from
A.M./P.M. to A.M./P.M.
Wed. from A.M./P.M. to A.M./P.M.
Thur. from A.M./P.M. to A.M./P.M.
Fri. from A.M./P.M. to A.M./P.M.
Sat. from A.M./P.M. to A.M./P.M.
Sun. from A.M./P.M. to A.M./P.M.
TOTAL # HOURS/WEEK:
EXTENDED LEAVE
Is the employee on extended leave (maternity, disability, etc.)?
Yes
No
The employee returned from an extended leave (maternity, disability, etc.) on: On what date did the extended leave begin:
TEMPORARY/SEASONAL EMPLOYMENT
Is the employee considered to be a temporary hire?
Yes
No
If yes, what is the last date of guaranteed employment?
If the employee is seasonal, please give: Last day of work before break: Expected date of return following break:
I understand that the information I am providing will be used to determine the above-named employee’s eligibility for subsidized child care.
Employers Signature(s) Date
X
CY 925 5/06
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Standard Employment Verification Form PDF

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