Student Eligibility Questionnaire Form - State Of Washington - Employment Security Department

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State of Washington – Employment Security Department
TeleCenter/Adjudication Center
BYE
Student Eligibility Questionnaire
Name
Social Security No.
Telephone No.
-
-
(
)
-
Claimant’s Name and Address:
Please return this form by mail or fax to:
We have a question about your eligibility for unemployment benefits. You have the right to an opportunity to be heard before a decision is
made. You are entitled to have with you any person, including an attorney, to represent you during any interview. You may present
evidence, documents or witnesses. You are entitled to cross-examine witnesses or parties present. You are entitled to a copy of all records
or documents relevant to your case. I have read and understand my rights.
I waive my right to an in-person interview. The requested information is enclosed.
I request a telephone interview. Please contact me at the number listed above.
I request an in-person interview.
_________________________________________________
____________________
Signature
Date
An individual must be immediately able and available for full-time work and be actively seeking work to be eligible for benefits.
Your enrollment and/or attendance at school raise a question regarding your eligibility. We will determine your eligibility based on
your answers to the following questions.
Name, address and phone number of school or training facility:
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Name of training program or major: ______________________________________________________________________________
Is this training full-time or part-time as defined in the school’s course catalog? F/T _____ P/T _____
School counselor/contact name and phone number: __________________________________________________________________
____________________________________________________________________________________________________________
I have invested $ _________________ (tuition, books, fees, room, board and expenses)
I began this training program on ___________________________________.
I will complete the training program/graduate on _________________________________.
I registered for this quarter or term on _______________________________________.
Classes began this quarter: ______________________Classes will end this quarter: ___________________
I am a Freshman ______ Sophomore _______ Junior ______ Senior ______ N/A _______
List specific jobs you will be qualified to do after completion of training: _________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
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