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 Page 2

Verified by:

Date:

- 2 -

Los Angeles County Department of Mental Health Stipend Program

Employment Verification Form

Employment Information – 12 Months Completed Employment

What position does this employee hold?

Number of hours per week the employee worked?

Employee Initial Start Date:

What is the date of completion of 12 months full time employment for this employee?

Has this employee been on leave, outside of regular vacation or sick time, in the last

12 months? If so, what was the time period?

Name of Agency/Program:

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.

Verified by:

Date:

The information requested on this form is required for completion of the DMH Stipend

Contract Obligation and Employment Payback.

Please send this form to:

James Ferreira, M.S.W.

The Long Beach Foundation

6300 E. State University Drive, Suite 180

Long Beach, CA 90815

Los Angeles County Department Of Mental Health Stipend Program Employment Verification Form - Msw Page 2