SSN: _______________________________________ 

                                                                    Employer: ___________________________________ 

I, _________________________ (Employee Name), do hereby certify that I received an offer of employment 

from ____________________________________________________________ (Employer Name and Address) 

on ________________ (Date) and authorize the Pennsylvania Bureau of Workers' Compensation Bureau to release all information from Bureau files. 

I affirm the information I have provided herein is true. I understand that if I make any false statements which I do not believe to be true and thereby mislead the public servant to whom this request is directed in performing his/her official function, I may be subject to punishment as provided in the Crimes Code, 18 Pa. C.S.A. 4904. 

Dated: ______________________ Signed: _________________________________ (Employee) 

I, ____________________________ (Name), _________________________________ (Title with Employer), an 

employee of and acting as agent for ________________________________________ (Employer), do hereby 

certify that ________________________________________________ (Employer), has extended an offer of 

employment to _______________________________ (Employee) on ___________________ (Date) and, I agree that information requested from the Pennsylvania Bureau of Workers' Compensation with regard to 

__________________________ (Employee Name) will be used by ___________________________ (Employer) 
in conformance with both the Americans with Disabilities Act and the Pennsylvania Human Relations Act. 

I affirm the information I have provided herein is true. I understand that if I make any false statements which I do not believe to be true and thereby mislead the public servant to whom this request is directed in performing his/her official function, I may be subject to punishment as provided in the Crime Code, 18 Pa. C.S.A. 4904. 

Dated: _______________________________ Signed: ______________________________________ 

Title: ______________________________________ 
 

Form - WCPA