4-04 - e-Verify Compliance Form PDF Fill-In.pdf
PDF 125 KB Posted
- Attached to
- 2026 Heidelberg Township Seal Coating Project
- Solicitation number
- Not on record
- Issued by
- Lawrence County, Pennsylvania
About this file
This is a Public Works Employment Verification Form issued by the Commonwealth of Pennsylvania requiring compliance with the Public Works Employment Verification Act through utilization of the federal E-Verify Program operated by the United States Department of Homeland Security. The form applies to contractors and subcontractors engaged on public works projects in Pennsylvania and must be completed and returned to the contracting public body prior to contract award. Contractors and subcontractors are required to verify that all employees are authorized to work in the United States and must utilize the federal E-Verify Program 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. The form requests company information including legal name, mailing address, whether the entity is a contractor or subcontractor, the contracting public body name, contract/project number, project description, project location, and the date of enrollment in E-Verify.
The authorized representative of the company must attest under penalty of law that the company is in compliance with the Public Works Employment Verification Act as of the date of signature and that all information contained in the verification form is true and correct. Documentation confirming use of the federal E-Verify Program upon each new hire must be maintained in the event of investigation or audit. The form requires the signature, printed name, phone number, and email address of the authorized representative along with the date of signature. Submission of false or misleading information in connection with this verification is subject to sanctions provided by law.
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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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