Form Lb-0490 - Mass Separation Notice - Tennessee Department Of Labor And Workforce Development

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STATE OF TENNESSEE
DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT
MASS SEPARATION NOTICE
(To be used only for lack of work separations)
Date of notice __________________________
Last day worked _________________________
(month, day, year)
(month, day, year)
We
permanently
temporarily*
ceased to employ the following workers:
*If temporary separation give probable duration in “REMARKS” COLUMN.
Worker’s Name
Social Security Number
Date Entered Employ
Occupation
Remarks
First
M I
Last
(where work performed) ___________________________________________________________
All of above workers worked at
Was separation caused by lack of work?
YES
NO
Employer Name ____________________________________________________
Employer Account Number __________________
Employer’s Address
Street/P O Box __________________________________________________________________________
City _________________________________
State _____
Zip Code _____________________
Employer Representative _________________________________________
Title ________________________________________
Area Code/Phone Number _______________________________
Ext. _________
E-Mail Address ____________________________________
Signature of Employer Rep ___________________________________
To be used only by arrangement with representatives of the Department of Labor and Workforce Development.
LB-0490 (R5/05)

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