6-Public Works Employment Verification Form.pdf
PDF 110 KB Posted
- Solicitation number
- US.260533
- Issued by
- Montgomery County, Pennsylvania
About this file
Public Works Employment Verification Form Summary
This is a Public Works Employment Verification Form utilized by the Commonwealth of Pennsylvania for contractors and subcontractors on public works projects, specifically referenced for Lower Gwynedd Township's traffic signal maintenance and infrastructure projects in Montgomery County, Pennsylvania. The form requires contractors and subcontractors to verify compliance with the Public Works Employment Verification Act through enrollment and utilization of the federal E-Verify Program (EVP) operated by the United States Department of Homeland Security. Contractors must complete and return this form to the contracting public body prior to contract award, affirming that as of the verification date, the company is in compliance with employment verification requirements and that all employees hired are authorized to work in the United States. Additionally, contractors agree to utilize E-Verify for all new hires within five business days of the employee start date throughout the duration of the public works contract, with documentation of E-Verify usage to be maintained for potential investigations or audits.
The form requires completion of company information including legal name, mailing address, and designation as either a contractor or subcontractor, along with project details such as the contracting public body, contract/project number, project description, and project location. An authorized representative of the company must sign and date the form, attesting under penalty of law that all information provided is true and correct. The form includes a fillable digital version with fields for company details, contact information, and certification date, ensuring standardized compliance documentation across all public works projects subject to Pennsylvania's employment verification requirements.
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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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