Appendix 10 – Self Employment Verification Template To: From:
In the event of query contact: Telephone:
Employment confirmation
Date
Thank you for taking the time to complete this form. We need some information about your employment for contract performance monitoring purposes. Your first name Your last name Your National Insurance Number Please complete sections 1 to 8 below as appropriate 1 I confirm that I have started or returned to work on a self employed basis as a : Your Company name The address I am trading from is:
2 3
4
This self employment is This self employment is This self employment This self employment is
a new job; Now complete parts, 5, 6 and 8 a return to an existing job; Now complete parts, 5, 6 and 8 increases hours for an existing job by more than 8 hours; Now complete parts, 5, 6, 7 and 8 increases hours for an existing job to 16 hours or more per week;Now complete parts, 5, 6, 7
and 8
5 6
The date I started or returned to self employment (or increase in hours occurred) was: I confirm that on the first day of self employment or recommencement or increase in hours occurred, I expected it to last at least 13 weeks Yes No
7 8
There has been a change in hours, my previous total weekly hours were: My current or new total weekly hours are:
Hours per wk Hours per wk
Certification My name
(please print)
Date Telephone No.
Signature
Please return this form to the address at the top. Thank you.