Engineering, Science And Technology Scholarship Employment Verification Form
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1WEST VIRGINIA HIGHER EDUCATION POLICY COMMISSION
ENGINEERING, SCIENCE AND TECHNOLOGY SCHOLARSHIP PROGRAM
EMPLOYMENT VERIFICATION FORM
Name of Recipient: ____________________________________________________________
Current Address: ____________________________________________________________
____________________________________________________________
Current Telephone Number: _____-_____-__________
This is to certify that I will be/was working FULL-Time in an engineering, science or
technology related field as determined by the Higher Education Policy Commission in the
state of West Virginia.
NAME OF BUSINESS
__________________________________________________
ADDRESS OF BUSINESS
__________________________________________________
__________________________________________________
ENGINEERING__________
SCIENCE __________
TECHNOLOGY ___________
Please provide a brief job description.
_____________________________________________________________________________
_____________________________________________________________________________
Dates of Employment:
From: ______/______/_____ To ______/______/ _____
(Please complete this form for one ACADEMIC Year only)
SIGNATURE _________________________________________________________________
DATE: ________/__________/_____________
SOCIAL SECURITY NUMBER _____-____-______
I certify that the person named above is/was employed FULL-Time for the period stated
above.
SIGNATURE OF SUPERVISOR
____________________________________________
DATE: _________/_________/_________
NAME AND ADDRESS OF EMPLOYER
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
Return
West Virginia Higher Education Policy Commission
Form To:
Engineering, Science and Technology Scholarship
1018 Kanawha Boulevard, East, Suite 700
Charleston, West Virginia 25301
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