CSBG EVL

ATTN.: ____________________________________
Employment Verification for PRINT NAME _____________________________________________________
SSN# _______________________________________
By this signature_____________________________________________ I authorize release of the following
employment related information to WorkSource.
Date of Hire ___________________________________
First day of work ___________________________________
Job Title ___________________________________
Hours worked per week __________________________________
Starting wage $__________________________________
Date of Last Salary Increase __________________________________
Current wage $__________________________________
Employed more than 90 consecutive days YES ( ) NO ( )
Benefits YES ( ) NO ( )
If no longer employed, last day of work ________________________
Reason for leaving _____________________________________________________
Employer’s name:
Employer’s address:
________________________________________________________
_________________________________________________________
Phone: ____________________________________ Fax: _______________________________
Employer Representative and Title: _________________________________________________________
Employer signature: __________________________________ Date:
____________________________
OFFICE USE ONLY
Vendor Placement
School Name _____________________________
Direct Placement
Employee Name __________________________
Please Check One:
Enrolled
Not Enrolled
If Enrolled:
New
Carry-Over