Public Servant Employment Verification Form

The employer’s certification should be obtained prior to the term the scholarship is being requested. The

scholarship will not be granted until the documentation is submitted. Please submit to the Admissions Office for

initial awarding and to the Financial Aid Office for renewal purposes.

Williamson College, 274 Mallory Station Road, Franklin, Tennessee 37067 / FAX: 615.771.7810

School Term: ____________________________________ Month / Year (Office use only)

Student Information

Full Name of Student___________________________________________ Date of Birth ________________

Address_________________________________________________________________________________

_________________________________________________________________________________

Relationship to Employee:

______Self,

______Spouse,

_______Child (under age 24)

Pursuing: _______undergraduate degree,

________graduate degree

Employee Information (must be employed full-time)

________________________________________________________________

Full Name of Employee

Employee’s Position_____________________________________________________________________

Employee Contact Phone Number___________________________________________________________

Home Address

_____________________________________________________________________

Employer _____________________________________________________________________________

Employer Address_______________________________________________________________________

____________________________________________Phone Number______________________________

Supervisor’s Name and contact number ______________________________________________________

We individually do hereby certify that all of the information contained above is true, correct, and complete to the

best of our knowledge. We hereby acknowledge receipt of a copy of the rules of this scholarship, and that to the full

extent of our knowledge and information both the employee and the student are fully qualified for this scholarship

under the rules. If following enrollment, the student is found to be ineligible for this award, the student will be

responsible for reimbursement of scholarship funds received during the period of ineligibility.

Student Signature and Date_______________________________________________________________________

Employee Signature and Date _____________________________________________________________________

Employer Signature and Date _____________________________________________________________________

Public Servant Employment Verification Form - Williamson College