Employment Verification Form
MedCertify.com 1169 Eastern Parkway Suite 2252Louisville, KY 40217P: 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.
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, 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.
Leave this empty:
Your legal name
Your email address
If you have questions about the contents of this document, you can email the document owner.
Document Name: Employment Verification Form
Agree & Sign