Employment Verification Form
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1EMPLOYMENT VERIFICATION FORM
I hereby authorize my employer to release the following information to CareerSource Pinellas and the Workforce
Board of Pinellas County.
Name: _______________________________
SSN: ____________________
Employment Information:
Job Title: ____________________Hourly Wage: _________ Gross Weekly Wage: _____________
Date of Hire: __________________
Date of first paycheck: ____________________
Currently Working
FT
PT
# of Hours per week_______
Seasonal
Pay Frequency:
Daily
Weekly
BI-Weekly
Monthly
Other __________
Not Eligible for Benefits
Eligible for:
Medical
Sick/Personal Leave
Vacation
Currently Not Working:
On Sick Leave
On Regular Leave
FMLA
on Leave of Absence
On Suspension
Resigned/Quit on _________
Terminated on ________
Reason: _______________________
Company Name: ____________________________________ Phone: _______________
Address: __________________________________ City: ________
Florida Zip: _______
__________________________________________________
_____________________
Employer's Representative Printed Name
Title
__________________________________________________
___________
Employer’s Representative Signature
Date
Or:
Hours verified: week of ________________________ total weekly hours worked ______
(use Monday
week of ________________________ total weekly hours worked ______
to Sunday)
week of ________________________ total weekly hours worked ______
(must be
week of ________________________ total weekly hours worked ______
specific)
week of ________________________ total weekly hours worked ______
week of ________________________ total weekly hours worked ______
_______________________________________________________
___________
Phone Verification completed by (staff name)
Title
Date
Please fax to: ____________________________________
*PRIVACY ACT STATEMENT: Pursuant to 42 U.S.C. 1320b-7 (a) (1) (Social Security Act) and 7 C.F.R. 273.6, disclosure of your social security number
is mandatory. Social security numbers will be used by the Agency for program administration including verification purposes, distinguishing one
individual from another, and for tracking and reporting purposes.
CareerSource Pinellas is an equal opportunity employer/program. Auxiliary aids and services are available upon request to individuals with disabilities.
All voice telephone numbers listed may be reached by persons using TTY/TDD equipment via the Florida Relay Service at 711.
Updated: 11-3-08;Updated 02-06-14
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Parent category: Legal