MedCertify.com 
1169 Eastern Parkway Suite 2252
Louisville, KY 40217
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.

Graduate/Employee:

Company Name:  

Job Title:  

Job Duties:  

Hire/ Start Date:

End Date (if applicable):

Total Hours Worked per Pay Period:   

Form Completed by (Name & Title):  

If obtaining the above verification by phone, Medcertify.com 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.

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Your legal name

Your email address

Please Confirm full name and signature.

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Signature Certificate

Document name: Employment Verification Form

Unique Document ID: 6dda9e24fb50d40a794271a687229748308dacb5

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Timestamp	Audit
August 23, 2022 9:48 AM EDT	Employment Verification Form Uploaded by MedCertify Education - [email protected] IP 2600:1700:7b18:ec90:f519:77dc:9e72:7bd5
December 15, 2022 10:09 AM EDT	Chelsea Givens - [email protected] added by MedCertify Education - [email protected] as a CC'd Recipient Ip: 99.190.9.234
February 27, 2023 11:33 AM EDT	Chelsea Givens - [email protected] added by MedCertify Education - [email protected] as a CC'd Recipient Ip: 99.190.9.234
May 2, 2023 1:20 PM EDT	MedCertify EDU - [email protected] added by MedCertify Education - [email protected] as a CC'd Recipient Ip: 99.190.9.234
December 5, 2023 9:28 AM EDT	MedCertify EDU - [email protected] added by MedCertify Education - [email protected] as a CC'd Recipient Ip: 2600:1700:7b18:ec90:8d24:39d6:9bf0:e250

This audit trail report provides a detailed record of the online activity and events recorded for this document.

https://medcertify.com/

Audit Trail Serial# 67f1d6cf6944b0c134739a1282a3b0c0