Employment Certification Form printable pdf download

Office of Student Financial Services

EMPLOYMENT CERTIFICATION FORM

PERMISSION FOR RELEASE OF INFORMATION (to be completed by applicant)

Name:

HUID#:

Current Address: (address to which LRAP Payment should be sent not employer’s address)

Street

City

State

Country

Zip/Postal Code:

I authorize my employer

(name of organization)

to complete the information below regarding my employment for purposes of my participation in the

Loan Repayment Assistance Program.

Nature of Employer: (Please Circle One)

Non-profit

Government

Applicant Signature:

______________________________________

Date:

_____________________

EMPLOYMENT CERTIFICATION (to be completed by employer)

The above named individual has applied for Loan Repayment Assistance. Please complete this form and

return it to our office. If you have questions, please feel free to contact us at

lrap@hks.harvard.edu

Position Title:

_________________________________________________________________________________

Date employment began:

_____________

Date employment ends:

_____________________

(if applicable)

Yearly Salary Gross:

_____________

Effective Date of Salary:

_____________________

Please indicate any anticipated changes in salary (including bonuses) with effective dates: __________________

_________________________________________________________________________________________________

Please list financial benefits (including bonuses, housing, food allowances, and loan repayment assistance

please write “none” if no additional benefits): _________________________________________________________

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Initial each section verifying each statement is true for the above employee

Employment is full-time paid employment and represents the full amount of the compensation received

by the applicant.

This position pays a salary which is sufficient to meet the full amount of the LRAP applicant’s living

expenses.

This employer is a non-profit or governmental employer.

________________________________

________________________________________

__________________

Authorized Signature

Printed Name and Title

Date

Name of

___________________________________________________________________________________

Employer:

Employer Address:

___________________________________________________________________________

Phone ( ) ________________________

Email: ___________________________________________

10-15-2013 Employer Cert Form

Employment Certification Form

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