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Update Employment Schedule Verification

Name of Employee:
Email:
Employee ID #:
Name of Child(ren):

Company/Business

Name of Company:
Phone Number:
Company Address:
City:
State:
Zip:

To Be Completed By Employer

Change of Work Schedule Effective Date:
Hire Date:
Job Title:
Description of Work:
Usual Business Hours:
Actual Worksite Address (if different from above):
Phone Number:
City:
State:
Zip:
Type of Schedule:

If SET Work Schedule, please provide start & end time per day (example: 8am-5pm)

Sunday

Start Time:
End Time:

Monday

Start Time:
End Time:

Tuesday

Start Time:
End Time:

Wednesday

Start Time:
End Time:

Thursday

Start Time:
End Time:

Friday

Start Time:
End Time:

Saturday

Start Time:
End Time:

If VARIABLE Work Schedule, please mark all possible days of work

Sun:
Mon:
Tues:
Wed:
Thurs:
Fri:
Sat:
Total Number of Hours Per Week:
Earliest Work Start Time:
Latest Work End Time:
Minimum Hours a Day:
Maximum Hours a Day:
Minimum Days Per Week:
Maximum Days Per Week:

I CERTIFY UNDER PENALTY OF PERJURY THAT THE ABOVE STATED INFORMATION IS TRUE AND ACCURATE

Employer Name:
Employer Title:
Phone Number:
Date:
By checking this box, I am certifying that the above stated information is true and accurate: