Form Ece-Cc-1b - New Employment Verification - West Virginia Department Of Health And Human Resources
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1West Virginia Department of
Health and Human Resources
New Employment Verification
This form is to verify new employment situations in which the applicant has not yet received pay and is unable to provide pay stubs as
proof of employment. Once the applicant has received one month’s worth of pay stubs, copies must be given to the agency.
Applicant/Employee Name: __________________________ Employer/Company Name:_________________________
Address:_________________________________________
Employer Address:_______________________________
_________________________________________
_______________________________
Phone: __________________________________________
Phone Number: _________________________________
I hereby request that my employment information be released to:
I understand that this information will be kept confidential and will be used for program purposes only.
_____________________________________
___ /___ / ___
Signature of Applicant
Date
This Section to Be Completed By the Employer
The following information is needed regarding the applicant’s employment:
1. Business Hours of Operation: ________ to _______ Business Days of Operation _______ to_________
2. Employee’s Hire Date: ___ /___ /___
Position: ________________________________
Q Hourly Employee, Rate of Pay per Hour $__________
3. Rate of Pay:
Q Salary Employee, Yearly Salary $ ____________
Q Other (piecework, commission only, etc.)$ ___________
4. Frequency of Pay:
Q Every Week Q Every Other Week Q Twice a month Q Once per month Q Other (please specify):__________
5. Additional Compensation
(please check all that apply and list the average amount received per pay period):
Q Commission __________ Q Tips__________ Q Incentive Pay__________ Q Bonuses ________
Q Overtime________
Q Other__________
Q No Additional Compensation Given
6. Number of Hours Worked per Week: _______ Number of Hours worked per day: _________
7. Work Schedule: (please check all that apply)
Q The Employee works overnights
Q The Employee works evenings
Q On Call Employee
Q The Employee’s schedule varies Q The Employee works a regularly scheduled shift from _____ to ______
Possible Work Shifts:
____________________________________________________________________________________
_____
8. Please check all days that the employee could be expected to work:
Q Sunday
Q Monday
Q Tuesday
Q Wednesday
Q Thursday
Q Friday
Q Saturday
Employer Signature: _______________________________________________
Date: ___ /___ / ___
Name/Title
ECE-CC-1B (1/2005)
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