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Signature of Employee Date TO BE COMPLETED BY EMPLOYER: Business Name: Business Address: Telephone Approx Hire Date: Job Title: Circle how often the employee gets paid: Weekly Every Two Weeks Twice Monthly Monthly Please indicate the employee’s work Schedule (Examples: “M-F, 8 am to 5 pm” or “11 am to 7pm-4 days on 2 days off” or “M-Sun Days Vary, 12 Midnight – 7 am”) Enter Work Schedule: Does this schedule vary Yes No If yes, please explain below: PLEASE NOTE: A minimum of 25 hours per week participation in work or training is required for eligibility for child care assistance through Workforce Solutions..
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