Employer Statement Form
Employee Information:
Employee's Full Name:
First Name
Last Name
Position/Job Title:
Department:
Date of Hire:
-
Month
-
Day
Year
Date
Employment Details:
Current Employment Status:
Full-time
Part-time
Temporary/Contract
Other
Work Schedule:
Specify the regular work hours and days, if applicable.
Compensation:
Specify the employee's salary, hourly wage, or other compensation details.
Benefits:
List any benefits provided to the employee (e.g., health insurance, retirement plans).
Leave Balances:
Specify the employee's current leave balances (e.g., vacation, sick leave).
Performance and Conduct:
Performance Evaluation:
Provide a brief overview of the employee's performance, if available.
Disciplinary Actions:
Indicate if there have been any recent disciplinary actions or performance-related issues.
Work History:
Work History with the Company:
Provide a summary of the employee's work history with the company, including any promotions or changes in responsibilities.
Employment Verification:
Verification of Employment:
The employee is currently employed.
The employee was employed.
Reason for Separation (if applicable):
If the employee is no longer with the company, provide the reason for separation.
Contact Information:
Supervisor's Full Name:
First Name
Last Name
Supervisor's Title:
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Certification:
*
I certify that the information provided in this statement is accurate and true to the best of my knowledge.
Employer's Signature:
Date
-
Month
-
Day
Year
Date
Submit
Should be Empty: