Employment Verification Form 3Employment Verification Form 3
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Employment Verification Form
EMPLOYEE’S NAME:

EMPLOYER’S PHONE #: (

PLACE OF EMPLOYMENT:

)

I authorize the release of this information and give permission to the Child Care Information Services (CCIS) agency to verify all information contained in this form.

X

Employee’s Signature(s)

Date

THE FOLLOWING SECTIONS MUST BE COMPLETED BY THE EMPLOYER.
IS THE ABOVE-MENTIONED EMPLOYEE NEWLY HIRED?
JOB TITLE:

! Yes

! No

EMPLOYMENT START DATE:

EMPLOYMENT INCOME
HOURLY RATE:
$

AVERAGE DAILY TIPS:
$

GROSS PAY:
$

NEXT PAY DATE:

FREQUENCY OF PAY:
! Weekly ! Bi-weekly (26 pays/year) ! 2x month (24 pays/year) ! Monthly

! No
DOES THE EMPLOYEE RECEIVE PAYSTUBS? ! Yes
EMPLOYMENT SCHEDULE (Please indicate the days and hours the employee works and indicate whether the hours occur during A.M. or P.M.)
NOTE: If the schedule varies, please give a 4-week sample schedule.
WEEK ONE
Dates: from
WEEK TWO
Dates: from
WEEK THREE Dates: from
WEEK FOUR Dates: from
to
to
to
to
A.M./P.M. to
A.M./P.M. Mon