Employment And Salary Verification Form {HR-712}

EMPLOYMENT VERIFICATION FORM Name (First, Ml, Last) Maiden and/or Former Name(s) (If applicable) Address Date of Birth (Month/Day/Year) / / Social Security # - - Employment # 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) 6. Base Salary Monthly Annual 7. Substitute Service (# of days) / / / / From / / To / / / / From / / To / / / / / / From / / To / / / / / / From / / 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 10. Reason for Leaves of Absence (EG,PERSONAL ILLNESS, PERSONAL REASONS, MATERNITY, CHILD CARE ?) 11. Medical documentation on file? From / / To / / YES NO From / / To / / YES NO From / / To / / YES NO 12. Were the positions listed in Item 2 covered by Social Security? YES NO 13. Was this employee a member of a pension fund while in the position listed in Item 2? YES NO If yes, is this employee receiving or entitled to receive a retirement benefit? YES NO 14. Is the employer a public or private entity? Public Private 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. Employer's Certifying Signature Please give the name and address of the fund's central office. Title Date Phone # A merican LegalNet, Inc. ©www.FormsWorkFlow.com