Wage Verification of Employment Form

WAGE VERIFICATION OF EMPLOYMENT FORM

Requestor Information

Requesting Company:

Employee Information

Employee Name:

Employee ID / Badge #:

Last 4 of SSN:    Date of Birth:

Employer / Payroll Information

Employment Details

Job Title:

Department:    Supervisor:

Date Hired:    Termination Date (if applicable):

Employment Status

Full-time    Part-time    Temporary    Contract

Compensation & Pay Details

Hourly Rate:    Annual Salary:

Pay Frequency:    Overtime Eligible:

Employment Verification Questions

Is employee currently employed?   Yes   No

If no, reason for separation:

Is rehire authorized?   Yes   No

Employee Authorization (if applicable)

I authorize the employer named above to disclose the wage and employment information requested to the Requesting Company for use in evaluating credit, tenancy, or other legitimate business purposes. I understand that false statements may have legal consequences.

Employee Authorizes Release:

Certification by Employer

The undersigned certifies that the information provided on this form is true, correct and complete to the best of the signer’s knowledge. The employer acknowledges that this information is provided in response to a legitimate request and may be relied upon by the Requesting Company. Deliberate misrepresentation of facts may subject the employer to civil or criminal penalties under applicable law.

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