Employment And Wage Verification Form (Page 3 of 5) in pdf

Employment And Wage Verification Form Page 3

EMPLOYMENT AND WAGE VERIFICATION FORM

I, ______________________________________, authorize my employer, ___________________________________,

(Employee Name)

(Company Name)

Wilkes Public Health Dental Clinic.

to release information regarding my income to the

________________________________________

______________________________________________

Signature of Patient

Date

________________________________________

_______________________________________________

Printed Name of Patient

Patient Phone Number

Beginning date of employment: _____________________________ Date of first pay: ________________________

Hourly wage: ______________ Number of hours employee works weekly: _________________________________

How often paid? (Circle one)

Weekly

Bi-weekly

Monthly

Other: ________________________________

What day of the week is pay received? _______________________________

Do you expect any changes in rate of pay or hours worked? Yes No If Yes, explain: ________________________

______________________________________________________________________________________________

Does your employee receive bonuses? Yes No If Yes, how often are they received: (Circle one)

Yearly Every 6 months Other: ___________________________________________________________________

Does your employee have health insurance? Yes No If Yes, name of company: ___________________________

_____________________________________________________________________________________________

Is employee on paid leave of absence? Yes No

_____________________________________________________________________________________________

Employer’s Name and Title (Printed)

______________________________________

____________________________ _______________________

Employer’s Signature

Phone Number

Date

(This information is for the Wilkes Public Health Dental Clinic use only)

Employment And Wage Verification Form Page 3