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1200 First Street, NE | Washington, DC 20002 | T 202.442.4090 | F 202.442.5315 | www.dcps.dc.gov
VERIFICATION OF PREVIOUS EMPLOYMENT
Please forward this application to your previous employer and return to DCPS Staffing:
EMAIL: dcps.staffing@dc.gov
FAX: (202) 442-5316
APPLICANT: PLEASE COMPLETE THIS SECTION
EMPLOYEE NAME: ______________________________________________________________________
ADDRESS: ___________________________________________________________________
CITY: ___________________________ STATE: ________ ZIP CODE: ____________________
PHONE NUMBER: ___________________________ SSN: ____________________________
FORMER SCHOOL OR PLACE OF EMPLOYMENT: ___________________________________________
LOCATION: _________________________________________________________________________
TITLE OF POSITION: __________________________________________________________________
l, ____________________ authorize the release of my employment history with my previous employer.
Signature of Applicant
THIS SECTION IS TO BE COMPLETED BY PREVIOUS EMPLOYER:
Your professional assistance in completing this form is appreciated. It is requested that this verification be returned as
soon as possible.
• lt is imperative that we have the specific day as well as the month and year of employment with your agency.
• lf there was a break in service, indicate each period of employment separately.
FROM: Month ______ Day ______ Year ______ TO: Month ______ Day ______ Year ______
FROM: Month ______ Day ______ Year ______ TO: Month ______ Day ______ Year ______
Check one:
□ This person was employed full-time . □ This person was employed part-time
lf part-time, please indicate the number of hours per week: _____
_______________________________ __________ ________________
Signature Date
_____________________________ _____________ _________________________
Title Print Name
_______________________________ ___________ ___________________________
Address City, State, Zip Code
By signing and submitting this document, you are assuring that all of the information stated is accurate to the best of your
knowledge. You are also acknowledging that any fraudulent information identified will result in the prospective candidate being
ineligible for employment with DCPS.