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

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Los Angeles County Department of Mental Health Stipend Program
Employment Verification Form (MFT)
This Employment Verification Form is to be completed by the employer and submitted to: MFT
Consortium, Phillips Graduate Institute, c/o Jose Luis Flores, M.A., 5445 Balboa Blvd., Encino,
CA 91316-1506. 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?
Does employee have bilingual capacity?
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 MFT Consortium/Phillips Graduate Institute use only.
Verified by:
Date:
1

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