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WAGE VERIFICATION FORM
Requesting Party
Name __________________________
Phone __________________________
E-Mail __________________________
Fax __________________________
Employee Consent
I, __________________________, authorize and hold harmless of any legal and financial
liability my employer to release to the requesting party listed above. I understand that this
information may be verified by phone, fax, or e-mail.
Signature ________________________ Date __________ Print ________________________
TO BE COMPLETED BY THE EMPLOYER ONLY
Employee Job Title: ________________________ Start Date: __________
On Leave? Yes No
If Yes, Type of Leave: __________________________________
If Yes, Return Date: __________
Monthly Average
Hourly Pay: $__________ Commission: __________ Tips: __________
Pay Period: Weekly Bi-Weekly Monthly Paid in Cash? Yes No
Work Schedule
MON
TUES
WEDS
THURS
FRI
SAT
SUN
From
To
Do Hours Vary? Yes No
If Yes, Explain: _______________________________________
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EMPLOYER CERTIFICATION
Employer / Company Name: ________________________
Address: ________________________ City: ________________________ State: __________
Phone: ________________________ E-Mail: ________________________
I certify that the information listed above is true and accurate to the best of my knowledge.
Signature ________________________ Date __________ Print ________________________
Title: ________________________
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