Employee Certification Form

Name of Business:

The business listed above is participating in the First Source Job Referral program through the City of St. Louis and St. Louis Agency on Training and Employment (SLATE). One of the goals of the program which is funded through incentives from the City of St. Louis is to provide access to jobs for qualified candidates and assist businesses with recruitment. The First Source Agreement requires all program participants (employers) to collect the following information from employees hired for a new job, position created with incentives from the City of St. Louis. All information collected will be kept confidential and will be used solely by the City of St. Louis and SLATE for purposes of monitoring and documenting the success of the First Source program.

Employee Name:

Home Address:

City:	State:	Zip Code:

Email Address:

Job Title:	Start Date:

Full Time or Part Time:

Are you a Participant in Missouri Work Assistance (MWA)?:

Are you a Veteran?:

Were you employed prior to accepting your new job?:

I certify that the information provided above is true and complete to the best of my knowledge and belief as on the date of my signature below. I understand that the information provided by me may be verified by the City of St. Louis, and SLATE.

If completed with electronic signature by checking box on signature line certifies the information provided above is true to the best of my knowledge and belief as on the date of my e-signature.

Signature:	Date:

Please Fax Form to: 314-621-8952 or Save to E-mail: slatecertification@stlworks.com or
Mail to: 1520 Market St. 3rd Floor St. Louis, M0 63103, ATTN: SLATE Business Department.