Los Angeles County Department Of Mental Health Stipend Program Employment Verification Form (Mft) (Page 2 of 2) in pdf

Los Angeles County Department Of Mental Health Stipend Program Employment Verification Form (Mft) Page 2

Los Angeles County Department of Mental Health Stipend Program

Employment Completion Form

Employment Information – 12 Months Completed Employment

Employee

Full Name:

Last

First

M.I.

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:

Was this position within

Specialized Foster Care, or

MHSA Funded? __________

Please explain. _____________________________________________________

Name of Authorized Agency

Representative:

______________________________

Title:

_________________________

Address:

City, Zip:

Business phone #:

Email address:

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:

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

Contract Obligation and Employment Payback.

Please send this form to:

Jose Luis Flores, M.A.

MFT Consortium of Greater Los Angeles

Phillips Graduate Institute

5445 Balboa Blvd.

Encino, CA 91316-1506

Los Angeles County Department Of Mental Health Stipend Program Employment Verification Form (Mft) Page 2