Fillable Employment Verifcation Form printable pdf download

Marguerite Ross Barnett Memorial Scholarship Program

Employment Verification Form

3515 Amazonas Drive, Jefferson City, MO 65109-5717 •

Phone: 573-751-2361 Fax: 573-751-6635 Information Center: (800) 473-6757

INSTRUCTIONS

This form must be completed and submitted to the student financial aid office at the Missouri school you are attending, or that you plan

to attend, at the time that the financial aid office requests the scholarship funds. The completed verification form may be submitted to

the student financial aid office at the school by you or the employer. The verification form is to be kept by the school for file purposes.

I. STUDENT SECTION

Complete this section and submit the form to your employer. Be sure to include the complete name and address of the school you are

attending, or that you plan to attend, so the employer may submit the form to the student financial aid office at the school.

Last Name

First Name

Social Security Number

Period of Enrollment: Month __________ Year __________ to Month __________ Year __________

Name of the approved Missouri school you are attending, or that you plan to attend

Street Address City State Zip Code

I, the applicant, certify that the information contained in Section I of this form is true, complete, and correct. (Your

signature also authorizes the MDHE to verify your employment with your employer.)

Print Name of Student Signature of Student Date

. EMPLOYER SECTION

Complete this section of the form. The completed form may be submitted by you to the student financial aid office at the school the

student is attending or plans to attend. The name and address of the school are listed in Section I above. The completed form may also

be given to the student to be submitted to the school.

Name of Employer

Phone

Employer Street Address

State Zip Code

Is the applicant currently employed and compensated for at least twenty (20) hours or more per week?

o Yes o No

Dates of the most recent week that the applicant was employed and compensated for at least twenty (20) hours or more:

Month _________ Day _________ Year _________ to Month _________ Day _________ Year _________

Note: The applicant must be employed and compensated for at least twenty (20) hours or more per week at the time the

scholarship funds are credited or delivered to the applicant.

I, the employer, certify that the information contained in Section II of this form is true, complete, and correct to the best of my knowledge.

Print Name of Supervisor/Employer Signature of Supervisor/ Employer Date

AS A REMINDER, THE EMPLOYMENT VERIFICATION FORM MUST BE RETURNED TO THE INSTITUTION LISTED IN SECTION I.

Employment Verifcation Form