20120815 NHLWAA EMP VERIF FORM 2012
This form must be completed by the employer/former employer.
Name
*
First Name
Last Name
Employer Name
*
Employer Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Employer Phone Number
*
-
Area Code
Phone Number
FAX Number
-
Area Code
Phone Number
EMPLOYEE Name
*
First Name
Last Name
Signature
*
Starting Date of Employment
*
Hourly Rate of Pay
*
Type of Employment
*
Full Time
Part Time
Temporary
Hours per week
Frequency of Pay
*
Weekly
Bi-Weekly
Other
Last 4 weeks of pay Date
*
-
Month
-
Day
Year
Date
Net Amount of Pay
*
Last 4 weeks of pay Date
*
-
Month
-
Day
Year
Date
Net Amount of Pay
*
Last 4 weeks of pay Date
*
-
Month
-
Day
Year
Date
Net Amount of Pay
*
Last 4 weeks of pay Date
*
-
Month
-
Day
Year
Date
Net Amount of Pay
*
Direct Deposit
*
YES
NO
Employment Status
*
Still Employed
Termination / Separation
If termination / separation, please indicate last date of employment:
If termination / separation, please indicate reason:
Lay Off
Voluntary Resignation
Dismissed with Cause
Temporary Leave (medical or otherwise)
Retired
Other
Does this employee receive any of the following:
Credit Union Account
Life Insurance
Short-term Disability
Long-term Disability
Sick Pay
Retirement Plan
Medical Insurance
Name of authorized staff completing form
*
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
Employer Email
example@example.com
Signature
*
Date
-
Month
-
Day
Year
Date
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