4-FrontEnd-PWEmplymnt verificatnfm.pdf
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- Cumberland County, Pennsylvania
About this file
This is a Public Works Employment Verification Form issued by the Commonwealth of Pennsylvania for use by contractors and subcontractors on public works projects. The form documents compliance with the Public Works Employment Verification Act and confirms that contractors utilize the federal E-Verify Program operated by the U.S. Department of Homeland Security. Contractors must verify employment eligibility for all employees hired after January 1, 2013, and agree to verify all new hires within five business days of their start date throughout the duration of the public works contract. Documentation confirming E-Verify usage must be maintained for investigations or audits. The form requires the authorized representative's signature, affirming that all information provided is true and accurate, with understanding that submission of false or misleading information subjects the contractor to sanctions.
This particular form applies to the Apple Street Phase 2 Improvements project in Lemoyne Borough, Cumberland County, Pennsylvania, which involves roadway reconstruction, infiltration trench installation, and associated work. The contract is subject to multiple regulatory requirements including the Pennsylvania Prevailing Wage Act, Federal OSHA conditions, Pennsylvania Act 229 of 2002, the Underground Utility Line Protection Law, the Pennsylvania Human Relations Act, non-discrimination employment regulations, and the Public Works Employment Verification Act. Sealed bids are due by 2:00 PM on Tuesday, January 27, 2026, with a 10 percent bid bond or certified check required. Questions must be submitted online through PennBID by 12:00 PM on Friday, January 23, 2026. The contract is subject to prevailing wage requirements and all standard public works compliance conditions applicable to Pennsylvania municipal projects.
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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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