Form Ub-101-A - Work Search Log - Arizona Department Of Economic Security

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UB-101-A (10-99)
ARIZONA DEPARTMENT OF ECONOMIC SECURITY
Page
WORK SEARCH LOG
from (date) _________________ to next visit
(WORK SEARCH LISTED IS SUBJECT TO PERIODIC VERIFICATION)
CLAIMANT'S NAME (Last, First, M.I.)
SOC. SEC. NO.
( ! ONE COL.)
RESULTS
NAME OF PERSON
TYPE OF
FILED
DATE
COMPANY NAME
ADDRESS (No., Street, City, State, ZIP)
PHONE NO.
CONTACTED
WORK SOUGHT
APPL.
OTHER (Specify)
CERTIFICATION
I have answered these questions for the purpose of obtaining Unemployment Insurance. I understand that the law provides penalties for making false statements.
CLAIMANT'S SIGNATURE
DATE
DEPUTY'S SIGNATURE
DATE
Equal Opportunity Employer/Program • This form is available in alternative format by contacting your local office manager.

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