Employment Verification Form - Short Form printable pdf download

Employment Verification Form - Short Form

EMPLOYMENT VERIFICATION FORM

An application for Economic Support benefits was submitted to the Georgia Crime Victims Compensation

Program (CVCP) for consideration. To help the CVCP make the best possible decision in determining

eligibility, we would appreciate your assistance by providing the below information.

Victim/Employee:

Claim Number: _____________

1. Dates of employment:

From: ____/____/____

To: ____/____/____

2. Hourly Wage: $ ___________________

Annual Salary: $ ___________________



Employment type: Full-time

Part-time

Number of hours worked per week _________

__________________________________________

___________________________________________

Company Name (print name)

Employer (print name)

___________________________________________

Employer Signature

Date: _________/_________/____________

Telephone No.: _______-_______-________

PLEASE NOTE:

TO BE VALID, This form must be attached to a blank copy of the employer’s business letterhead or

business card that includes the business contact information AND the documents must be faxed or

mailed by the EMPLOYER.

An Equal Opportunity Employer

Employment Verification Form - Short Form