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:  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

Please Confirm full name and signature.

Change fonts

• Draw Signature
  
• Type In Signature
  

Draw your signature with your mouse, tablet or smartphone Clear

I agree that I am and I agree this is a legal representation of my signature for all purposes just the same as a pen-and-paper signature

Insert Signature

I agree that I am and I understand this is a legal representation of my signature

Adopt & Sign

Signature Certificate

Document name: Employment Verification Form

Unique Document ID: a400b39e65794f0f3ac1a36e42d6c2f710adc935

Build. Track. Sign Contracts.

Timestamp	Audit
August 23, 2022 9:48 AM EDT	Employment Verification Form Uploaded by MedCertify Education - [email protected] IP 99.190.9.234
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

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