An Application Packet Page 12
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14Employment Verification Form
(To be completed by employer)
Applicant’s Name:
SS Number:
To: The employer of the undersigned:
Case Number:
This is your authorization to release the information concerning my employment as required below. In
order to establish eligibility for child care assistance with Workforce Solutions Northeast Texas,
verification of employment hours and income is required. Please complete this form as soon as possible.
It is required before I can be determined eligible for the program. You may fax to Workforce Solutions
Northeast Texas at (903) 794-8012 or (877) 329-6772.
Your cooperation and prompt return of this information is appreciated.
__________________________________________________
_________________________
Signature of Employee
Date
TO BE COMPLETED BY EMPLOYER:
Business
Name:
_______________________________________
Telephone #
__________________
Business
Address:
_________________________________________________________________________
Approx Hire Date: __________________
Job Title: ___________________________________
Circle how often the employee gets paid: |Weekly | Every Two Weeks | Twice Monthly | Monthly |
Please indicate the employee’s work Schedule (Examples: “M-F, 8 am to 5 pm” or “11 am to 7pm--
4 days on 2 days off” or “M-Sun Days Vary, 12 Midnight – 7 am”)
Enter Work Schedule: ________________________________________________________________
Does this schedule vary? Yes _____ No _______ If yes, please explain below:
PLEASE NOTE: A minimum of 25 hours per week participation in work or training is required for
eligibility for child care assistance through Workforce Solutions.
Avg. # Hours Worked per Week_________
Avg. Overtime Hours Worked per Week ___________
Hourly Rate of Pay: __________________
Hourly Rate for Overtime _______________________
Weekly Avg. of Tips
Amt. of other Employment Income (such as
Earned (if applicable): _________________
commission, incentive pay) _____________________
Yearly Avg. of Bonuses Received: _____________
Comments___________________________________________________________________
MUST BE SIGNED BY EMPLOYER
________________________________
_______________________
__________________
Person Completing This Form (Please Print)
Title
Phone #
________________________________
_______________________
Signature
Date
Updated 6-13
Form CS004
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