Work Verification Form

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WORK VERIFICATION
Name __________________________________
:_____________________ SSN: __________________
Phone
Return to: WORKING SOLUTIONS - City: ______________________________ CM Name: ________________________________
Employer Name: ___________________________________________________________________________________
Employer contact (name)
Best way to contact
Fax
Phone
E-mail
Other
Employer Address:
EMPLOYEE INFORMATION: Date employee started _______/________/_______ Position Title_____________________
Date employee began working the hours/wages listed below: _______/________/_______
NUMBER OF DAYS
SEASONAL
AVERAGE NUMBER OF HOURS PER WEEK
MONTHLY
HOURLY PAY
OTHER
WORKED PER
POSITION?
DO NOT PUT ‘VARIES’ – PLEASE GIVE AN ESTIMATED
SALARY
NUMBER OF HOURS PER WEEK
WEEK
YES OR NO
Is overtime anticipated?
YES
NO If “YES”, list avg. number of hrs/wk_________ Per Month___________
If employee just started working, when will 1st check be issued? ______/_______/_______
How many hours will this check cover? _______ If temporary assignment, est. assignment end date: ___/____/___
PAY DATE INFORMATION: How often is employee paid?
Weekly
Bi-weekly (Every two weeks)
What day of the week? _______________
Monthly
Semi-Monthly (Twice a month)
What date?(e.g. 1st & 15th) ___________
EXPECTED CHANGES:
Do you expect the number of hours to go up or down?
YES
NO
If yes, what date? _____/_____/_____
New number of hours? ____________ per week
Do you expect rate of pay to go up or down?
YES
NO
If yes, what date? _____/_____/_____
New rate of pay $ _______________________________
OTHER INCOME:
Employee receives:
Tips
Commissions
Bonuses
Overtime
Tip/Commission/Bonus/Overtime Amount: $ _______________ How often? _________________________________
OTHER BENEFITS AVAILABLE:
Health Insurance?
Start date _______________________
None
Other: ___________________
Sick Leave?
Start date _______________________
None
Other: ___________________
Working Solutions is required to follow up on your new employee’s status at 30, 90, and 180 days.
Employer’s Signature _____________________________________________
Date _____/_____/_____

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