Work Search Record - Pa
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1WORK SEARCH RECORD
___________________________________________________________________________________________________________
WORK SEARCH RECORD FOR WEEK BEGINNING SUNDAY _____________________ THROUGH SATURDAY ______________________
To be eligible for UC benefits, complete the work search record below. Refer to your
Pennsylvania UC Handbook
(Form UCP-1) for complete instructions or open the UC Work
Search Requirement Guide.
If you are working part-time, and earning more than your Partial Benefit Credit, initial here ___________
JOB APPLICATIONS/INTERVIEWS
WORK SEARCH ACTIVITY
#1
__________
_____________
____________________________________________
Date of Application
or Date of Interview
Date of Activity
________________________________________________
Employer
Type of Activity
_____________________________________
Employer Contact Name
______________________________________
_________________________________________
Employer Phone/Email
Location of Activity
_________________________________
_____________________________________________
How did you apply for the job
Contact Name
__________________________________________________
________________________________________
Results
Contact Phone/Email
#2
__________
_____________
____________________________________________
Date of Application
or Date of Interview
Date of Activity
________________________________________________
Employer
Type of Activity
_____________________________________
Employer Contact Name
______________________________________
_________________________________________
Employer Phone/Email
Location of Activity
_________________________________
____________________________________________
How did you apply for the job
Contact Name
__________________________________________________
_______________________________________
Results
Contact Phone/Email
#3
__________
_____________
____________________________________________
Date of Application
or Date of Interview
Date of Activity
_________________________________________________
Employer
Type of Activity
_____________________________________
Employer Contact Name
______________________________________
_________________________________________
Employer Phone/Email
Location of Activity
_________________________________
_____________________________________________
How did you apply for the job
Contact Name
__________________________________________________
_______________________________________
Results
Contact Phone/Email
EXEMPTION
Employer/Hiring Hall Name
Contact Name
Contact Phone/Email
Written Date of Recall (attach copy) _____
Union Hiring Hall
I certify that all information I have provided in this document is correct and complete. I acknowledge that false statements in this document are punishable pursuant to
18 Pa.C.S. §4904, relating to unsworn falsification to authorities.
First Name _____________________ M.I. ___ Last Name _____________________________________
Social Security Number XXX-XX- __ __ __ __ (last 4 digits)
Signature _______________________________________________
Date ____________________
A person who knowingly makes a false statement or knowingly withholds information to obtain UC benefits commits a criminal offense under Section 801 of the UC Law, 43
P.S. §871, and may be subject to a fine, imprisonment, restitution and loss of future benefits.
UC-304 REV 01-14 (Page 1)
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