5-Employment Verification.pdf
PDF 125 KB Posted
- Attached to
- 2026 Street Rehab Project
- Solicitation number
- Not on record
- Issued by
- 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 is required for the South Front Street Sewer Lining Project and the 2026 Street Rehab Project with Wormleysburg Borough. Contractors and subcontractors must complete and return this verification form to the contracting public body prior to contract award. The primary service requirement is verification of compliance with the Public Works Employment Verification Act through enrollment in the federal E-Verify Program operated by the United States Department of Homeland Security. Contractors must affirm that all current employees are authorized to work in the United States and commit to utilizing E-Verify 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. Documentation confirming E-Verify usage must be maintained for investigations or audits.
The form requires completion of company legal name, business address, mailing address, contractor or subcontractor designation, contracting public body name, contract/project number, project description, project location, and the date of E-Verify enrollment. An authorized company representative must sign and date the form, attesting under penalty of law that all information is true and correct. The representative must provide printed name, phone number, and email address. This employment verification requirement applies to all bidders on Commonwealth of Pennsylvania public works contracts and is a mandatory compliance document for contract award eligibility.
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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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