Long Service Verification Form

Section 1 – To completed by the manager

Employee Name:Employee Number:Ward / DepartmentCBU:Service Milestone Achieved:Date Milestone Achieved:Service Detail:Please include a breakdown of NHS organisations and dates where service was achievedAttachments:Please include detail of any attachments included to verify serviceManager Name: Manager Job Title:Manager Signature: Date:

Section 2 – To completed by the Assistant HR Advisor / HR Advisor

Date Received:Service Verified: YearsEvidence:Please include detail of evidence used to verify service (e.g. ESR, Employee file, documents provided by employee)Date evidence received:Date sent to Comms:Assistant HRA/HRA Name:Signature: Date: