Sample Application: Add Washington Employment

Note: When you select your employer from the list, many of these fields will already be filled in. If you could not find your employer from the list, you will need to complete all of the fields yourself. You will continue to complete these pages until you have given us information on all of your employers in the last 24 months.

asterisk Employer Name: ____________________________________

asterisk Mailing Address: ____________________________________

Additional Address: ____________________________________

asterisk City: ___________________

asterisk State:

asterisk ZIP __________________ - ____________

asterisk Telephone: (including area code) (________)   ________ -  ___________

asterisk Start Date (mm dd yyyy) ___________   ___________   ___________

asterisk End Date (mm dd yyyy)     Help ___________   ___________   ___________

asterisk Estimated Gross Monthly Pay while employed with this employer:     Help $_________ . _____    Salary Calculator

asterisk Reason no longer employed: Reason for Separation
Depending on your reason for separation, an addition field may appear:

Please provide a brief explanation for your separation/reduced hours from work. Your comments will be seen by this employer. You have only 59 characters including spaces available. Don't worry about not being able to tell exactly what happened. You will be mailed a questionnaire and given the opportunity to provide complete and separation information.
asterisk Comments:
______________________________________________________

Note: Your last employer and certain other of your employers are notified that you have filed an unemployment claim. The reason for separation that you provided will appear on the form.

asterisk Have you applied for or are you receiving a Pension from this employer? Yes    No
asterisk Did you or will you be paid Holiday Pay from this employer for this week? Yes    No
asterisk Did you or will you be paid Vacation Pay from this employer for this week? Yes    No
asterisk Do you have a definite return to work date with this employer on or before [ date ]? Help
Note: This is a dynamically calculated date that is the Sunday five weeks from the Sunday date of the week you are filing this claim. 		Yes    No
If you answer "yes" an additional field will open:
asterisk Date you will return to work:
__________   __________   __________

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