Training Benefits Work History Form

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TRAINING BENEFITS WORK HISTORY
P
P
LEASE
RINT
You are not eligible for Training Benefits if your current skills are in demand in your labor market. Additionally, eligibility for Training Benefits may be
determined by your work history for the past seven years. In your job description, list all skills, tools, and equipment you used.
Name
Social Security Number *
Last Employer
Job Title
Mailing Address
City
State
ZIP
I worked for this employer
From _______ / ______ / ______ To _______ / ______ / ______
Month
Day
Year
Month
Day
Year
Reason you are no longer working
1 _ Voluntary Quit
4 _ Still Employed
7 _ Fired for Felony/Gross Misdemeanor
My hourly/monthly pay for
My total earnings for this
for this employer:
this period of employment
2 _ Fired
5 _ Lack of Work
8 _ Partially Employed
period of employment
(Check One)
was $________________
was $________________
3 _ Strike/Lockout
6 _ Leave of Absence
9 _ Lack of Work, Reduced Hours
Job Description
(did what,
using what, to what?)
Next Employer
Job Title
Mailing Address
City
State
ZIP
I worked for this employer
From _______ / ______ / ______ To _______ / ______ / ______
Month
Day
Year
Month
Day
Year
1 _ Voluntary Quit
4 _ Still Employed
7 _ Fired for Felony/Gross Misdemeanor
Reason you are no longer working
My hourly/monthly pay for
My total earnings for this
for this employer:
this period of employment
period of employment
2 _ Fired
5 _ Lack of Work
8 _ Partially Employed
(Check One)
was $________________
3 _ Strike/Lockout
6 _ Leave of Absence
9 _ Lack of Work, Reduced Hours
was $________________
Job Description
(did what,
using what, to what?)
Next Employer
Job Title
Mailing Address
City
State
ZIP
I worked for this employer
From _______ / ______ / ______ To _______ / ______ / ______
Month
Day
Year
Month
Day
Year
Reason you are no longer working
1 _ Voluntary Quit
4 _ Still Employed
7 _ Fired for Felony/Gross Misdemeanor
My hourly/monthly pay for
My total earnings for this
for this employer:
this period of employment
2 _ Fired
5 _ Lack of Work
8 _ Partially Employed
period of employment
(Check One)
was $________________
was $________________
3 _ Strike/Lockout
6 _ Leave of Absence
9 _ Lack of Work, Reduced Hours
Job Description
(did what,
using what, to what?)
Next Employer
Job Title
I worked for this employer
Mailing Address
City
State
ZIP
From _______ / ______ / ______ To _______ / ______ / ______
Month
Day
Year
Month
Day
Year
Reason you are no longer working
1 _ Voluntary Quit
4 _ Still Employed
7 _ Fired for Felony/Gross Misdemeanor
My hourly/monthly pay for
My total earnings for this
for this employer:
this period of employment
2 _ Fired
5 _ Lack of Work
8 _ Partially Employed
period of employment
(Check One)
was $________________
was $________________
3 _ Strike/Lockout
6 _ Leave of Absence
9 _ Lack of Work, Reduced Hours
Job Description
(did what,
using what, to what?)
If you have additional work history during the last seven years, use the back of the form.
Signature __________________________________________________________________________
Date __________________________
* IF YOU DO NOT GIVE US YOUR SOCIAL SECURITY NUMBER, WE CANNOT PROCESS YOUR APPLICATION FOR TRAINING BENEFITS
EMSX 8813 (Rev 6/00)
2

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