Fillable Employment Verification Form printable pdf download

Employment Verification Form

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Employment Verification Form

Complete this form to verify employment for the Practitioner Registry. This is the required employment

verification form that must be submitted to verify any new early childhood employment. Please contact

The Early Childhood Project if you have any questions at 1.800.213.6310. This form can emailed to

ecp@montana.edu or mailed to PO Box 173540 Bozeman, MT 59717.

Employer Certification:

I certify that ____________________________________ is currently working as a

_______________________________.

(position title)

This is a :

□Family/Group Child Care

□Child Care Center

□Head Start

□Early Head Start

□Public School

□Agency Staff

□Other_______________________________

This individual is employed________ hours per week for____________months per year,

and began working______________(mm/dd/yy).

Hourly wage: $_______________/hr. Date of last wage increase:____________ (mm/yy).

This person works with the following age range:

□Infants (0-12 Months)

□Toddlers (13-36 Months)

□Preschoolers (37-PreK)

□Elementary (K-5th Grade) □Adults

Signature of Employer:_________________________________________________

Name of Program:_____________________________________________________

PV # (facility license number, if applicable):_____________________________

Note:

Wage information is requested to track and report data to advocate for increased compensation for the early child-

hood workforce. This data will only be reported in the aggregate (no personal or program information will be connected to

the wage info provided).

I certify all information given is true and correct. If you are self-employed we understand that you will

need to sign for yourself.

Applicant Signature:____________________________________Date:__________________________

Employment Verification Form

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