2023 PLC Work Hours Verification (4).pdf

Participant Work Hours Verification Form Public Lands Corps

Each section and data field of this form must be completed and certified by the responsible party. The Program Participant is defined as the candidate seeking Public Lands Corps Certification. The Partner Organization is defined as the non-FWS entity that directly employs the Participant. The Project Supervisor is defined as the FWS employee with oversight of the Participant and their project.

NOTE: Individual forms are required for each separate position used to accumulate the 640 required hours. Each form must be signed by their respective project supervisor and partner organization.

Program Participant

Participant Name:

Partner Organization:

Phone Number:

Personal Non-University Email:

Address:

I certify that the information provided is accurate and true. Yes No

Program Participant Signature:

Partner Organization Representative

Task Agreement Number:

Partner Organization Name:

Partner Organization Address:

Representative Name and Title:

Phone:

Email address:

Start Date of Project:

End Date of Project:

I certify that the information provided is accurate and true. Yes No

Partner Organization Representative Signature:

FWS Project Supervisor or Representative

Name and Title:

Duty Station:

Phone:

Email address:

Were at least 120 hours of the participant’s project completed on or in support of public lands or Indian lands? Yes No

Total Project Hours Completed:

Location of Project:

PLC Project Type (select all that apply):

Wildlife and Habitat Management/ Restoration

Law Enforcement

Wildfire and Fuel Management

Visitor Services

Diversity and inclusion

Transportation/ Community Connectedness

Infrastructure and Maintenance

Emergency and Natural Disaster

Invasive Species Removal

Climate Mitigation and Resilience

Trail Building/ Restoration

Project Duties:

Was the Member’s Performance Satisfactory? Yes No

Provide details and justification of participant’s performance:

I certify the information provided is accurate and true. Yes No

FWS Representative or Project Supervisor’s Signature: