34-Doc 00 73 00 - 02 - APPENDIX B PUBLIC WORKS EMPLOYMENT VERIFICATION FORM.pdf
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- Bucks County, Pennsylvania
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This document is a Public Works Employment Verification Form issued by the Commonwealth of Pennsylvania, applicable to contractors and subcontractors on public works projects including the Bristol Township 2026 Road Paving, Inlet Replacement, and Curb Ramp Program. The form requires contractors to affirm compliance with the Public Works Employment Verification Act through utilization of the federal E-Verify Program (EVP) operated by the United States Department of Homeland Security. Contractors must verify that all employees hired after January 1, 2013 are authorized to work in the United States and must use the federal EVP to verify employment eligibility for each new hire within five business days of the employee start date throughout the contract duration. Documentation confirming EVP usage must be maintained for potential investigations or audits.
An authorized representative of the contracting company must sign and attest that the information provided in the verification form is true and correct, with understanding that submission of false or misleading information is subject to legal sanctions. The form requires completion with project-specific details including the contract number, project description, project location, contractor name and address, and the contracting public body information. This verification requirement applies to all contractors and subcontractors working on public works projects within Pennsylvania and must be submitted as part of contract compliance documentation.
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Text version
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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