EMPLOYMENT VERIFICATION SCPHA

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EMPLOYMENT VERIFICATION SCPHA

EMPLOYMENT VERIFICATION FORM

Date

EMPLOYER’S NAME

EMPLOYER’S ADDRESS

PHONE

EMPLOYEE NAME

SOCIAL SECURITY

THIS PORTION TO BE COMPLETED BY EMPLOYER

DATE HIRED

END DATE

IS EMPLOYEE PAID

WEEKLY BIWEEKLY SEMI-MONTHLY MONTHLY

EMPLOYEE’S AVERAGE NUMBER OF HOURS PER PAY PERIOD:

STRAIGHT TIME:

OVERTIME:

EMPLOYEE’S HOURLY WAGE:

PLEASE LIST ANY OTHER COMPENSATION AND DESCRIPTION:

PREVIOUS PAY RATE DURING THE PAST 12 MONTHS:

PLEASE LIST GROSS EARNINGS FOR THE LAST 12 MONTHS:

ARE THERE ANY ANTICIPATED CHANGES IN PAY RATE DURING THE NEXT 12 MONTHS?

YES NO

IS SO, PLEASE LIST BELOW:

EFFECTIVE DATE:

EFFECTIVE AMOUNT

EFFECTIVE PER

ARE THERE ANY ANTICIPATED CHANGES IN NUMBER OF HOURS WORKED DURING THE NEXT 12 MONTHS?

YES NO

IS SO, PLEASE LIST BELOW:

EFFECTIVE DATE:

EFFECTIVE AMOUNT

EFFECTIVE PER

EMPLOYER SIGNATURE

PRINT NAME:HUMAN RESOURCE DEPT

TITLE

DATE