Employment Verification Form
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1EMPLOYMENT VERIFICATION FORM
DHHS, Division of Public Health, Licensure Unit
Office of Nursing & Nursing Support
P. O. Box 94986
Lincoln, NE 68509-4986
Fax (402) 471-1066
Telephone (402) 471-0537
NURSE AIDE INFORMATION (Either the Nurse Aide or the Employer can complete this section):
Social Security Number ____________________
Name ____________________________________________________________________________________
Last
First
Middle Initial
Other Previously Used Last Names(s)____________________________________________________________
Address ___________________________________________________________________________________
Street
Apt. #
City / State
Zip Code
Home Phone # (____) ______________ Work or Cell Phone # (____) ______________
Signature _____________________________________
Date____________________
(optional)
EMPLOYER: COMPLETE THIS SECTION
Employer’s name and mailing address:
______________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
Employer’s Telephone Number (___) _____________________
Brief Description of duties performed while employed:
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
All employers must complete the following section in the presence of a notary public:
I certify that the nurse aide named above (is/was) employed by me to perform nursing or nursing-related
services for monetary compensation from ____________________ to _______________________.
(month, day, year)
(month, day, year)
Signature ______________________________________
Date Signed ____________________
Title __________________________________________
Sworn and subscribed before me on this _____ day of ______________, 20__, In the County of ____________,
In the State of ____________________________.
_________________________________________
Signature of Notary Public
(SEAL)
_________________________________________
Date Commission Expires
Rev 8-07
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Parent category: Business