REOC Employer Verification

Thank you very much for taking the time to complete the following form. If you have any concerns and/or clarity is needed, please call

Brittney Turner, Job Placement Coordinator at 585.327.4062 or email bturner@brockport.edu.

Or

Leesah Zink, SNAP Job Developer at 585.478.1126 or email lzink@brockport.edu

Name and title of individual completing form: *
Telephone Number *
Email: *
Company Name: *
Company Address: Company Address: *
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Name of REOC student/graduate employed by your company Name of REOC student/graduate employed by your company * First Last
Employment Start Date: Employment Start Date: * / MM / DD YYYY
Currently Employed *

Currently Employed Yes No Other Other
Employment End Date (if applicable) Employment End Date (if applicable) / MM / DD YYYY
Present/Last Position: *
Pay Rate: * $ Dollars . Cents
How often is pay received? *

How often is pay received? Hourly Weekly Bi-Weekly Monthly Annually Other Other
Average hours worked in a week? *

Average hours worked in a week? 0-15 15-20 20-25 25-30 30-35 35-40 40+
Using the mouse draw your signature into the box below. *

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.
Today's Date Today's Date * / MM / DD YYYY
Add another REOC student/graduate? *

Add another REOC student/graduate? Yes No