10-Exhibit J - Public Works Verification Form.pdf
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- Solicitation number
- Not on record
- Issued by
- Montgomery County, Pennsylvania
About this file
This is a Public Works Employment Verification Form issued by the Commonwealth of Pennsylvania for use by contractors and subcontractors bidding on public works projects. The form serves as a compliance document confirming that bidding entities have enrolled in the federal E-Verify Program (EVP) operated by the United States Department of Homeland Security and are adhering to Pennsylvania's Public Works Employment Verification Act. Contractors and subcontractors must complete and return this form to the contracting public body prior to contract award. The form requires the contractor to affirm current E-Verify enrollment, confirm all employees are authorized to work in the United States, and commit to verifying the employment eligibility of all new hires within five business days of their start date throughout the duration of the public works contract. An authorized company representative must sign the form and provide contact information including printed name, phone number, and email address.
The form mandates that all documentation confirming use of the federal E-Verify program for each new hire must be maintained for potential investigation or audit purposes. Submission of false or misleading information on the verification form subjects the contractor or subcontractor to sanctions provided by law. This requirement applies to all public works contracts in Pennsylvania and is a prerequisite to contract award, making E-Verify compliance a mandatory condition for any entity bidding on Commonwealth-funded construction or public works projects.
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Text version
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 today’s 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
| Company Legal Name: |
| Doing Business As: |
| Street Address 1: |
| Street Address 2: |
| City: |
| State: |
| Zip Code: |
| Contractor: Off |
| Subcontractor: Off |
| Contracting Public Body: |
| ContractProject Number: |
| Project Description: |
| Project Location: |
| Printed Name: |
| Phone Number: |
| Email: |
| Today's Date: |
| Name of Authorized Representative: |
| MM/DD/YYYY: |
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