Los Angeles County Department Of Mental Health Stipend Program Employment Verification Form

Los Angeles County Department Of Mental Health Stipend Program Employment Verification Form - Msw

Los Angeles County Department of Mental Health Stipend Program

Employment Verification Form - MSW

This Employment Verification Form is to be completed by the employer and submitted to: The Long

Beach Foundation, c/o James Ferreira, M.S.W., 6300 E. State University Drive, Suite 180, Long

Beach, CA 90815. The form is to be completed once at initial hire, and then again at the completion of

12 months full time employment.

Employee Information

Full Name:

Last

First

M.I.

Address:

Street Address

Apartment/Unit #

City

State

ZIP Code

Home Phone:

(

)

Alternate Phone:

(

)

E-mail Address:

Birth Date:

Social Security Number:

I understand I can be penalized by law, and will be required to repay the stipend financial aid if I misrepresent or

purposely give false information on this form.

Employee Signature:

Date:

Employment Information – Initial Hire Date

What position does this employee hold?

Number of hours per week the employee works?

What is the start date of continuous employment for this employee?

Name of Agency/Program:

Is this position within

Specialized Foster Care, or

MHSA Funded? Please explain.

Name of Authorized Agency

Representative:

Title:

Address:

City, Zip:

Business phone #:

SPA / Service Area:

I certify that the information I have given on this form is true and correct. I understand that purposefully providing false

information on this form may lead to legal penalty and the forfeiture of stipend financial aid for the employee.

Signature:

Date:

DO NOT COMPLETE THIS SECTION – For Long Beach Foundation use only.

Los Angeles County Department Of Mental Health Stipend Program Employment Verification Form - Msw

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