2-FrontEnd-PWEmplymnt verificatnfm.pdf
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- Cumberland County, Pennsylvania
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Commonwealth of Pennsylvania Public Works Employment Verification Form
This is a Public Works Employment Verification Form issued by the Commonwealth of Pennsylvania for use by contractors and subcontractors on public works projects. The form requires contractors to affirm compliance with the Public Works Employment Verification Act through participation in the federal E-Verify Program (EVP) operated by the United States Department of Homeland Security. Contractors must verify that all employees hired on or after January 1, 2013, are authorized to work in the United States and commit to utilizing the federal E-Verify system to verify employment eligibility for all new hires within five business days of the employee start date throughout the duration of the public works contract. The form requires documentation confirming E-Verify usage for each new hire to be maintained for investigation or audit purposes.
The form must be completed and signed by an authorized representative of the contracting company, who attests under penalty of law that all information provided is true and correct. The document includes fields for the employer's business name and address, the contracting public body, contract and project numbers, project description, and project location. False or misleading information submitted in connection with this verification is subject to sanctions provided by law. This form is a mandatory requirement for participation in Pennsylvania public works contracts and applies to all contractors and subcontractors involved in covered projects.
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COMMONWEALTH OF PENNSYLVANIA
PUBLIC WORKS EMPLOYMENT VERIFICATION FORM
Date _______________________
Business or Organization Name (Employer)_________________________________________________
Address _____________________________________________________________________________
City _____________________________________ State_____________ Zip Code ________________
Contractor {dzōŎƻƴǘNJŀŎǘƻNJ όŎƘŜŎƪ ƻƴŜύ
Contracting Public Body _______________________________________________________________
Contract/Project No ___________________________________________________________________
Project Description ____________________________________________________________________
Project Location ______________________________________________________________________
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 post
January 1, 2013 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: |
| Address: |
| City: |
| State: |
| Zip Code: |
| Contracting Public Body: |
| ContractProject No: |
| Project Description: |
| Project Location: |
| Name: |
| Business or Organization Name - Employer: |
| Signature: |
| Check Box1: Off |
| Check Box2: Off |
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