5-04 - e-Verify Compliance Form PDF Fill-In.pdf
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- 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 required by the Commonwealth of Pennsylvania for contractors and subcontractors on public works projects, specifically for the 2026 Heidelberg Township Seal Coating Project in Lebanon County, Pennsylvania. The form must be completed and submitted to the contracting public body prior to contract award. The project consists of approximately 25,344 square yards of single seal coat work, including all equipment, materials, labor, supervision, and testing services. Sealed proposals are due online via the PennBid Program by 11:00 a.m. prevailing time on April 27, 2026, with final questions due by 12:00 p.m. on April 24, 2026. A final addendum, if necessary, will be issued by 3:00 p.m. on April 24, 2026. No pre-bid conference will be held, and all bid documents are available at no cost online at pennbid.bonfirehub.com.
Each proposal must be accompanied by a bid bond or acceptable security in the amount of 10 percent of the total base bid, and bids will remain effective for 60 calendar days from the bid opening date. All bidders and subcontractors must be PennDOT pre-qualified in accordance with 67 PA Code Chapter 457 and PennDOT Form 408/2011. Under the Public Works Employment Verification Act, contractors and subcontractors must affirm their compliance with the federal E-Verify Program operated by the United States Department of Homeland Security and certify that all employees are authorized to work in the United States. Documentation confirming E-Verify usage for each new hire within five business days of employment must be maintained throughout the contract duration for potential investigation or audit purposes.
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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
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| Contractor: Off |
| Subcontractor: Off |
| Contracting Public Body: |
| ContractProject Number: |
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| Printed Name: |
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| Today's Date: |
| Name of Authorized Representative: |
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