Employment Verification Form

Date*
MM slash DD slash YYYY
Re: Verification of Income
Applicant Name
First Last
Company Name*
Employeer Name
First Last
Employer Email*
I hereby authorize the release of the requested information on this verification form.
Applicant's Signature*
Date*
MM slash DD slash YYYY
To be filled by Employer
Dear Employer: The above referenced individual has applied for residency at our community. The information that you will be providing will be used solely for the determination of residency eligibility. Please complete this form and fax to (757) 557-0918.
Hire Date
MM slash DD slash YYYY
Position
Hourly Rate/Salary
Hours/Week
Overtime Rate
Overtime Hours/Week
Tips
If Yes, How Much/Week
Commission
If Yes, How Much/Week
Shift Differential Pay
If Yes, How Much/Week
Employer Name (Print)
First Last
Title
Phone
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Re: Verification of Income