CCEMS Educational Pay Verification Form 

Name_________________SS#_________________ 

Date______________    

Name of Class:_________________________ 

Location:______________________________ 

Time in…………… ______  

Time out for Lunch  ______

Time in from Lunch ______ 

Time out from Class ______ 

Total hours………… ______ 

Instructor’s name (print):__________________________ 

Instructor’s signature: ____________________________ 

(edpayform.doc) 

 

Attach Course Outline, copy of Attendance Certificate, or other proof of attendance.