Fillable Printable Employment Verification From

Employment Verification From

EMPLOYMENT VERIFICATION FORM

DHHS, Divisi on of Public Health, L ic ensure Unit

Office of Nursing & Nursing Support

P. O. Box 94986

Lincoln, NE 68509-4986

Fax (402) 471-1066

Telephone (402) 471-0537

NURSE AIDE INFORMATION (Either the Nurse Aide or the Employer can complete this section):

Social Security Number ____________________

Name ____________________________________________________________________________________

Last First Middle Initial

Other Previously Used Last Names(s)____________________________________________________________

Address ___________________________________________________________________________________

Street Apt. # City / State Zip Code

Home Phone # (____) ______________ Work or Cell Phone # (____) ______________

Signature _____________________________________ Date____________________

(optional)

EMPLOYER: COMPLETE THIS SECTION

Employer’s name and mailing address:

______________________________________________________________

_____________________________________________________________________

Employer’s Telephone Number (___) _____________________

Brief Description of duties performed while employed:

___________________________________________________________________________________

All employers must co mplete the following sec t ion in the presence of a notary public:

I certify that the nurse aide named above (is/was) employed by me to perform nursing or nursing-related

services for monetary compensation from ____________________ to _______________________.

(month, day, year) (month, day, year)

Signature ______________________________________ Date Signed ____________________

Title __________________________________________

Sworn and subscribed before me on this _____ day of ______________, 20__, In the County of ____________,

In the State of ____________________________.

_________________________________________

Signature of Notary Public

(SEAL) _________________________________________

Date Commission Expires

Rev 8-07