3-Supporting Documents 2 Public Works Employment Verification Form.pdf
PDF 125 KB Posted
- Solicitation number
- US.261862
- Issued by
- Delaware County, Pennsylvania
About this file
This is a Public Works Employment Verification Form issued by the Commonwealth of Pennsylvania for use in connection with the City of Chester's Lead-Safe and Healthy Homes Program, which seeks qualified and certified lead abatement contractors for a pool of prequalified service providers. The form must be completed and returned to the contracting public body prior to contract award and applies to contractors and subcontractors engaged in public works projects. The form requires contractors to verify compliance with the Public Works Employment Verification Act through enrollment and ongoing participation in the federal E-Verify Program operated by the United States Department of Homeland Security.
Contractors must affirm on the form that all employees are authorized to work in the United States and commit to utilizing 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. An authorized company representative must sign and certify the accuracy of the information provided, acknowledging that submission of false or misleading information is subject to sanctions under applicable law. The form requires documentation of E-Verify usage to be maintained for investigation or audit purposes, and contractors must provide company contact information, project details, and the date of form completion as part of the verification process.
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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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