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If we select you for an interview to review your job search activities, please bring proof of your identity. We may review your logs any time up to 60 days past the end of your
benefit year or up to 30 days after receiving any benefits, whichever is later. We may call the employers listed to verify that you looked for work. Providing false information is
fraud that can result in a denial of your unemployment benefits and additional penalties.
Employer contacts and job search activities
How contact was made Contact person, job Type of contact
Date of contact Business name with complete mailing address/web address or
(Include phone number, complete e-mail address, or reference number, or (Include position applied for or name of
M/D/Y WorkSource office
confirmation for all contacts) confirmation notice approved WorkSource activity if applicable)
Business/WorkSource office name
In person Online Other Application / resume Inquiry
CONTACT 1
Fax: (……….)………………………………………...
City, state and zip code
E-mail: ………………………………………………..
E-mail: ………………………………………………..
Fax: (……….)………………………………………...
E-mail: ………………………………………………..
Fax: (……….)………………………………………...
E-mail: ………………………………………………..
Fax: (……….)………………………………………...
E-mail: ………………………………………………..
E-mail: ………………………………………………..
For The Employment Security Department is an equal opportunity employer and provider of programs and services. Auxiliary aids and
Week being verified Reschedule WS office name or # TeleCenter # Staff initials
services are available upon request to persons with disabilities. Auxiliary aids may include qualified interpreters and telecommunication
official devices (TTY) for hearing or speech impaired individuals. Individuals with limited English proficiency may request interpretive services
use only free of charge to the customer in order to conduct business with the department.
EMS 10313 . CC 7540-032-823 . Rev 8/10
NAME: .............................................................................................. ID: .................................................................
How contact was made Contact person, job Type of contact
Date of contact Business name with complete mailing address/web address or
(Include phone number, complete e-mail address, or reference number, or (Include position applied for or name of
M/D/Y WorkSource office
confirmation for all contacts) confirmation notice approved WorkSource activity if applicable)
Business/WorkSource office name
In person Online Other Application / resume Inquiry
CONTACT 7
Fax: (……….)………………………………………...
E-mail: ………………………………………………..
Fax: (……….)………………………………………...
E-mail: ………………………………………………..
Fax: (……….)………………………………………...
E-mail: ………………………………………………..
Fax: (……….)………………………………………...
E-mail: ………………………………………………..
Fax: (……….)………………………………………...
E-mail: ………………………………………………..
Fax: (……….)………………………………………...
E-mail: ………………………………………………..
Fax: (……….)………………………………………...
E-mail: ………………………………………………..
E-mail: ………………………………………………..