Employment Verification Form

On Sick Leave   On Regular Leave   On FMLA   On Leave of Absence   On Suspension  

Hours Verified:

Week Start Date Week End Date Hours Worked

ACKNOWLEDGEMENT & ELECTRONIC SIGNATURE

By signing your first and last name in the box below you are agreeing that all the information you have submitted is accurate and this document has been read, acknowledged, and authorized. I am also providing this information voluntarily and give CareerSource Pasco Hernando permission to contact my employer directly if needed to obtain any additional information. PRIVACY ACT STATEMENT: Pursuant to 42 U.S.C. 1320b-7(a)(1) (Social Security Act) and 7 C.F.R. 273.6, disclosure of your social security number is mandatory. Social security numbers will be used by the Agency for program administration including verification purposes, distinguishing one individual from another, and for tracking and reporting purposes.