Education/Employment Verification
Name
*
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Social Security Number
Gender
Academic Status
Enrolled
Graduate
Dropout
GED
School Attending
If enrolled in school.
Anticipated Grad Date
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
If enrolled in school.
Free or Reduced Lunch Eligible:
Yes
No
Application or Letter
If eligible for free or reduced lunch.
Graduate: Date Of Graduation
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
If graduated already.
Dropout: Last School attended
If dropped out.
Dropout: Date last attended school
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
If dropped out.
GED: Completion Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
If finished a GED.
Date of Transcript, Diploma or Certificate copy on file
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
If applicable.
Other Verification (if Applicable):
Employment
Employment Status
Employed
Unemployed
Employer
Position
Employment Documentation
Selective Service
Registration
Yes
No
N/A
Verification Number (from SSA or NA Reason):
Income
Household Income
Documentation
Government Assistance (type)
Documentation
Preview PDF
Submit
Should be Empty: