Employment Verification Form 
2704 Old Rosebud Rd, Ste. 130
Lexington, KY 40509
P: 800.511.2284

To the Employer:

This letter is to retrieve pertinent information required yearly for our school to maintain its licensure for education. The information you provide is confidential and only needed once to have on file with our license provider, therefore the form should be completed in its entirety. Any information given does not affect the recent graduate/your current/past employee in any way. We greatly appreciate you taking the time to complete this short form. If you have any questions or concerns you may contact us at the above number.


Job Title:  

Job Duties:  

Hire/ Start Date:

End Date (if applicable):

Total Hours Worked per Pay Period:  Pay Rate:  

Form Completed by (Name & Title):  

If obtaining the above verification by phone, staff must forward the completed Employment Verification form to the employer by mail, email or fax. Evidence of this being sent must be attached to this form and placed in the Placement Binder.

Leave this empty:

Signature arrow sign here

Signature Certificate
Document name: Employment Verification Form
lock iconUnique Document ID: 69e6cf3b6122bd564d02b40a1241584b04002ad5
Timestamp Audit
August 23, 2022 9:48 AM ESTEmployment Verification Form Uploaded by MedCertify Education - [email protected] IP
December 15, 2022 10:09 AM ESTChelsea Givens - [email protected] added by MedCertify Education - [email protected] as a CC'd Recipient Ip: