Fill - Free fillable PENNSYLVANIA PUBLIC WORKS EMPLOYMENT VERIFICATION FORM PDF form

COMMONWEALTHOFPENNSYLVANIA

PUBLICWORKSEMPLOYMENTVERIFICATIONFORM



Date_______________________



BusinessorOrganizationName(Employer)_________________________________________________ 

Address _____________________________________________________________________________ 

City_____________________________________ State_____________ZipCode________________



Contractor

^ƵďĐŽŶƚƌĂĐƚŽƌ;ĐŚĞĐŬŽŶĞͿ

ContractingPublicBody _______________________________________________________________ 

Contract/

ProjectNo ___________________________________________________________________ 

Projec

tDescription ____________________________________________________________________ 

ProjectLocation ______________________________________________________________________ 



Asacontractor/subcontractorfortheabovereferencedpublicworkscontract,Iherebyaffirmthatas

oftheabovedate,

ourcompanyisincompliancewit

hthePublicWorksEm

ploymentVerificationAct

(‘the Act’) through utilization of the federal E‐Verify Program (EVP) operated by the United States

Department of Homeland Security.To the best of my/our knowledge, all employees hired post

January1,2013areauthorizedtoworkintheUni

tedStates.

It is also agr

eed to that all public works contractors/subcontractors will utilize the federal EVP to

verifytheem ploymenteligibilityofeachnewhirewithinfive(5)businessdaysoftheemployeestart

datethroughoutthedurationofthepublicworkscontract.Documentationconfirmingtheuseofthe

federalEVPup

oneachnewhi

reshallbemaintainedintheeventofaninvestigationoraudit.

I, _________________________, authorized representative of the company above, attest that the

informationcontainedin thisverificationformistrueandcorrectandunderstandthatthesubmission

of false or misleading information in connection with the above verification shall be subject to

sancti

onsprovidedbylaw.



________________________________

AuthorizedRepresentativeSignature

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PENNSYLVANIA PUBLIC WORKS EMPLOYMENT VERIFICATION FORM

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