Unemployment Benefits Application

UNEMPLOYMENT BENEFITS APPLICATION

Claimant Personal Information

U.S. Citizen: Yes No

Position and Recent Employment Information

Most Recent Employer:

Was a separation notice or termination issued? Yes No

Prior Employment History (Most Recent Two Employers)

Employer 1

Employer 2

Education

Professional References

Eligibility and Availability

Are you able and available to accept suitable full-time or part-time work on short notice? Yes No

Are you actively seeking employment at this time? Yes No

Do you have any pending separation agreement, severance, or scheduled rehire date? Yes No

Legal Notices, Disclosures and Acknowledgements

At-Will Employment Statement: Submission of this application does not alter any at-will employment relationship the applicant may have with any prospective employer. Nothing in this application creates a contract of employment for any specified period.

Equal Opportunity: All determinations of eligibility for unemployment benefits and any related employment determinations will be made without regard to race, color, religion, sex, national origin, age, disability, or any other protected classification.

Certification of Accuracy: By signing below, the claimant certifies under penalty of law that all statements and representations on this application are true, correct, and complete to the best of the claimant's knowledge. The claimant understands that false statements, material omissions, or misrepresentations may subject the claimant to disqualification, monetary penalties, and criminal prosecution consistent with applicable law.

Authorization to Verify: The claimant authorizes any employer, educational institution, government agency, or other entity to release employment, wage, and other records relating to this claim to the administering agency and its authorized representatives for the purpose of determining eligibility, benefit amounts, or liability for overpayment. The claimant further authorizes wage verification and background checks as required to adjudicate this claim.

Consent to Repayment: The claimant agrees to notify the administering agency of any changes in employment, earnings, or availability for work and acknowledges responsibility to repay any overpaid benefits resulting from erroneous or fraudulent information.

I authorize the agency to contact prior employers for verification of employment and earnings: Yes No

Applicant Certification and Signature

I certify that I have read and understand the statements above. I understand that benefits may be denied or recouped if information is incomplete, false, or misleading. I authorize verification of all information provided on this application.

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