e-Verify_Compliance_Form_PDF_Fill-In.pdf
PDF 125 KB Posted
- Attached to
- Stormwater Fast Track Project (Contract 1) State and local contract opportunity
- Solicitation number
- 2025-ITB-087
- Issued by
- Lackawanna County, Mount Aetna CDP, Pennsylvania
About this file
This document is a Commonwealth of Pennsylvania Public Works Employment Verification Form designed to ensure compliance with employment eligibility regulations for public works contracts. The form requires contractors or subcontractors to affirm their enrollment in the federal E-Verify Program (EVP) operated by the U.S. Department of Homeland Security and verify the employment authorization of all employees hired for the project.
The form mandates that contractors utilize the EVP to verify the employment eligibility of each new hire within five business days of their start date throughout the contract duration. Contractors must maintain documentation confirming EVP usage and understand that submitting false or misleading information may result in legal sanctions. The form requires the authorized representative's signature, contact information, and attestation to the accuracy of the provided information, serving as a critical compliance document for public works contracts in Pennsylvania.
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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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