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Employment And Salary Verification Form HR-712 - Legal Forms
| Employment And Salary Verification Form Form. This is a Legal Forms form and can be used in Employment . |
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EMPLOYMENT VERIFICATION FORM Name (First, Ml, Last) Address Date of Birth (Month/Day/Year) / / Social Security # Maiden and/or Former Name(s) (If applicable) Employment # THIS SECTION TO BE COMPLETED BY EMPLOYER (Items 1-8 and 12- 14 must be completed for all requests. For leaves of absence items 9 to 11 must be completed.): The person named on this form is an Employee of (insert name) and wishes to purchase additional service credit. To assist this member in establishing additional service credit, please provide the required information below. Service under the Job Training Partnership Act or the Workforce Investment Act of 1998 must be identified as such. 1. Name of Employer: 2. Official Payroll Title 3. Date of Hire (Month/Day/Year) 4. Date of Permanent Appointment (MonthlDaylYear) 5. Employment Dates (MonthlDaylYear) (CERTIFY EACH YEAR SEPARATELY) (BOARDS OF ED. MUST USE SCHOOL YEARS) From From From From 6. Base Salary Monthly Annual 7. Substitute Service (# of days) / / / / / / / / / / / / / / / / / / / / / / / / To To To To / / / / / / / / 8. (BOARD OF EDUCATION CERTIFYING OFFICERS ONLY): Please indicate the number of months in each regular school year: 9. Dates for Leaves of Absence (Month/Day/Year) From From From 10. Reason for Leaves of Absence (EG,PERSONAL ILLNESS, PERSONAL REASONS, MATERNITY, CHILD CARE --) 11. Medical documentation on file? / / / / / / To To To / / / / / / YES NO 14. Is the employer a public or private entity? YES YES YES Public NO NO NO Private 12. Were the positions listed in Item 2 covered by Social Security? 13. Was this employee a member of a pension fund while in the position listed in Item 2? YES NO I hereby certify that the answers and information given are based upon available authentic public records and that they are true and correct to the best of my knowledge and belief. If yes, is this employee receiving or entitled to receive a retirement benefit? YES NO Please give the name and address of the fund's central office. Employer's Certifying Signature Title Date Phone # American LegalNet, Inc. © www.FormsWorkFlow.com
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