Child Care Employment Verification Form

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CHILD CARE EMPLOYMENT
VERIFICATION FORM
AUTHORIZATION:
To Whom It May Concern:
I hereby authorize you to provide any information in your possession regarding my job performance, length of
employment and character to:________________________________________________________________
Employee’s Signature: ____________________________________________________________________
VERIFICATION:
Name of Employee: ________________________________________SSN_________________________
Name of Employer: ______________________________________Phone: ( __ )_____________________
Address: ________________________________________________________________________________
1. Dates of Employnent:_____________________________to_______________________________
(month/year)
(month/year)
2. Number of Hours Worked per Week:_________________________________________________
3. Position Title:___________________________________________________________________
4. Duties and Responsibilites:_________________________________________________________
________________________________________________________
5. Additional Comments (optional):____________________________________________________
Verifier’s Signature: __________________________________Title: ________________________
**************************************************************************************
FOR OFFICE USE ONLY
Total Hours per week ___________ x 4.33 weeks per month = __________________________
Total hours per month ___________ x ____________ no. of months = _____________________
Total hours ____________________ ÷ 1250 hrs/years = _______________years

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