6-Public Works Employment Verification Form.pdf
PDF 125 KB Posted
- Attached to
- Pavement Marking Improvements Project
- Solicitation number
- Not on record
- Issued by
- Bucks 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. The form applies to the Pedestrian Crossing Improvement Project in Northampton Township, Bucks County, Pennsylvania. Contractors and subcontractors must complete and submit this form to the contracting public body prior to contract award. The form requires documentation of enrollment in the federal E-Verify Program (EVP) operated by the United States Department of Homeland Security, with verification that all employees hired are authorized to work in the United States. All public works contractors and subcontractors are required to utilize 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 for each new hire must be maintained for investigative or audit purposes.
The form requires an authorized representative of the company to attest under penalty of law that the information provided is true and correct. Submission of false or misleading information is subject to sanctions as provided by law. The form requests company legal name, mailing address, contracting public body name, contract or project number, project description, project location, date of E-Verify enrollment, and contact information for the authorized representative including signature, printed name, phone number, and email. No specific pricing, funding amounts, or contract term information is contained within this employment verification form itself, as it serves solely as a compliance document demonstrating adherence to Pennsylvania's Public Works Employment Verification Act.
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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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