Employment Verification Form
ADVERTISEMENT
1Employment Verification Form
Employee Name:
Date:
Social Security #:
Case #
Note to the Employee: It is your responsibility to return this information to your worker by: _
Failure to return this form will result in denial or termination of your case.
Your child day care worker is : _ __________________________ Phone: ___695-
Catawba County Social Services PO Box 699 Newton NC 28658 Fax 695-5691
Note to the Employer: The following information is necessary to determine your employee’s need for
child day care services. Please complete this form in ink and call if you have any questions. Thank you
for your prompt assistance in completing this form.
* * * Employees may not fill out or complete this form. * * *
This form must be completed in full by the employer.
Please list the beginning date of employment:
Pay rate:
Pay Schedule:
Wkly
BiWkly
1/Month
Other
_______
Number of hours scheduled per week:
Daily work schedule
am/pm to
am/pm
Circle days of week worked:
Mon.
Tues.
Wed.
Thurs.
Fri.
Sat.
Sun.
If days and hours vary, please specify:
___________________________________________
Is the traditional schedule full time:
___________________________________________
If employee is working less than full time, is it due
to slow schedule or absences? Please explain:
Is the position
If so, when is the expected ending
temporary?
date?
Please list the actual gross wages paid to this employee for the last four pay periods. List pay
dates and gross pay for each period.
Date Pay Received
Number of Hours Worked
Gross Pay (including tips)
Signature/Title of Person Completing Form
Date
Company Name
Telephone Number
Fax Number
Company Mailing Address
I:A1webdssDAYCAREWEBFORMSWageVeri.doc
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal