3-E-verify Compliance Form Fill-in.pdf
PDF 125 KB Posted
- Attached to
- Yoder Road (T-375) Sidewalk Connection
- Solicitation number
- US.261676
- Issued by
- Montgomery County, Pennsylvania
About this file
This is a Commonwealth of Pennsylvania Public Works Employment Verification Form related to the Yoder Road (T-375) Sidewalk Connection project in Lower Salford Township, Montgomery County, Pennsylvania. The form must be completed and returned to the contracting public body prior to contract award. Contractors and subcontractors are required to affirm compliance with the Public Works Employment Verification Act through enrollment and active participation in the federal E-Verify Program (EVP) operated by the United States Department of Homeland Security. All contractors and subcontractors must utilize E-Verify to verify employment eligibility of each new hire within five business days of the employee start date throughout the duration of the public works contract. Documentation confirming E-Verify usage for each new hire must be maintained for investigation or audit purposes. The form requires the authorized representative to certify that all information provided is true and correct, with understanding that submission of false or misleading information is subject to legal sanctions.
The form requires standard company information including legal name, doing business as designation, mailing address, and identification of whether the entity is a contractor or subcontractor. The authorized representative must provide signature, printed name, phone number, and email address. Bid submission for the project closes at 11:00 AM on January 26, 2027, via PennBID, with questions due by 5:00 PM on January 12, 2027. All bidders and subcontractors must be PennDOT pre-qualified contractors and comply with Pennsylvania's Prevailing Wage Act. Bids must be accompanied by a bid bond or certified check equal to 10 percent of the total bid amount.
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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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