00 45 46 Public Works Employment Verification Form.pdf

Street Address 2

City State Zip Code

Doing Business As:

(if different from Legal Name)

Commonwealth of Pennsylvania

Public Works Employment Verification Form Complete and return the form to the contracting Public Body prior to the award of the contract.

Company Legal Name: ___________________________________________________________

Mailing Address: ______________________________________________________

Check one: Contractor Subcontractor

Contracting Public Body: _________________________________________________________

Contract/Project Number: ________________________________________________________

Project Description: _____________________________________________________________

Project Location: _______________________________________________________________

Date Enrolled in E-Verify (MM/DD/YYYY): ___________________________________________

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 with the Public Works Employment 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 are authorized to work in the United States.

It is also agreed to that all public works contractors/subcontractors will utilize the federal EVP to verify the employment 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 upon each new hire 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 sanctions provided by law.

Authorized Representative Signature Date of Signature

Printed Name: _________________________________________________________________

Phone Number: ______________________ Email: ____________________________________

Street Address 1

Herbert, Rowland & Grubic, Inc. 00 45 46 - 1 011361.0461