Provider: Provider Staff: Date of Report: Employment Verification Client Name: VR Counselor: Date of Employer Birth: Contact/Title: Employer: Supervisor: Employer Employer Address: Phone: Employment Start Per Date: Week: Wage at 90 Job Title: Days: Job Date Successful Duties: Employment Outcome Achieved: Fringe Benefits: None Paid Vacation Paid Sick Leave Health / Dental / Vision Insurance Retirement Other: Comments:
Provider: Provider Staff: Date of Report: Employment Verification Client Name: VR Counselor: Date of Birth: Employer Contact/Title: Employer: Supervisor: Employer Address: Employer Phone: Employment Start Date: Per Week: Job Title: Wage at 90 Days: Job Duties: Date Successful Employment Outcome Achieved: Fringe Benefits: None Paid Vacation Paid Sick Leave Health / Dental / Vision Insurance Retirement Other: Comments: