42-Doc 00 73 00 05 - Appendix B - Public Works Employment Verification Form.pdf
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- Attached to
- 1121 Horsham Road Demolition (26-01054)
- Solicitation number
- US.258594
- Issued by
- 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 is required for the 1121 Horsham Road Demolition project (Contract No. 26-01054), a residential demolition project in Pennsylvania involving the abandonment of existing water and sanitary services at the mains, with subsequent grading and permanent stabilization of disturbed areas.
By submitting this form, contractors and subcontractors affirm compliance with Pennsylvania's Public Works Employment Verification Act through participation in the federal E-Verify Program (EVP) operated by the United States Department of Homeland Security. The form requires verification that all employees hired after January 1, 2013, are authorized to work in the United States. Contractors must utilize the federal E-Verify Program to verify employment eligibility for each new hire within five business days of the employee's start date throughout the duration of the public works contract, and documentation confirming such verification must be maintained for potential investigations or audits. The authorized representative of the contracting company must attest under penalty of law that the information provided is true and correct.
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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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