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Student Eligibility Questionnaire Form - State Of Washington - Employment Security Department Page 2

If these jobs are not available locally, are you willing to move to another area in order to work? Yes _____ No _____. If yes, what

areas? ______________________________________________________________________________________________________

What is your financial plan to complete training if your UI benefits run out? ______________________________________________

____________________________________________________________________________________________________________

What degrees or certificates do you hold and when (year) were they received? _____________________________________________

____________________________________________________________________________________________________________

My class schedule this quarter/term is:

Class Name

Course Number

Sem/Qtr. Hours

Class Times

Class Days

I spend or will spend __________ hours in class, class preparation, and study each day.

My classes are available other hours and the school will let me change at this stage of the school term:

Yes _____ No _____

I am willing to change or drop my classes: Yes _____ No _____ If no, please explain:

____________________________________________________________________________________________________________

I am seeking: Full-time _____ Part-time _____ Temporary _____ (check all that apply) work in the following occupations:

____________________________________________________________________________________________________________

Where have you looked for work the last two weeks?

Date

Employer Name & Address

Type of Work

How Contacted

Results

I am available: Days _____ Swing _____ Graveyard _____ (check all that apply)

Student Eligibility Questionnaire Form - State Of Washington - Employment Security Department Page 2