Form Center

2. Requestor Information
   Please enter the information the name and contact information for the individual requesting the information.
4. First Name
5. Last Name
7. Address
9. City
10. State
11. ZIP Code
13. Phone Number
14. Email Address
15. Fax Number
17. Employee Name
    Enter the name of the employee for whom you are requesting verification
19. Which of the following best describes your verification type?

    1. Potential Employment
    2. Housing/Mortgage
    3. Government Services
    4. Legal Proceedings
    5. None of the above (all other requests should be submitted to the City Attorney's office)
21. Verification Type

    1. Basic Employment Details (Start Date, Current Employment Status, Current Position)
    2. Expanded Employment Details (Basic Details + Wages and Earnings)
23. Waiver / Release
    If you are requesting expanded employment details, please submit a copy of the employee's signed waiver/release. If you request expanded details and you fail to submit a release, your request will not be responded to.
25. Certification*

    1. I certify.

    By submitting this form, I certify that the information I have provided is true and accurate to the best of my knowledge and that it is my responsibility to contact the City of Winston-Salem Human Resources Department as soon as I become aware of any changes. Submitting false information may result in legal action being taken against me.
Leave This Blank:


27. 1. Receive an email copy of this form.
28. Email address

    This field is not part of the form submission.

29. Submit Submit and Print

* indicates a required field