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Student Eligibility Questionnaire Form - State Of Washington - Employment Security Department Page 3

I can work _____________ hours per week/day.

In the past I have worked full-time and attended school: Yes _____ No _____ If yes, how were you able to manage it: (occupation,

flexible employer, class schedule, credits)?

____________________________________________________________________________________________________________

If offered full-time work that conflicts with my school and I can’t change my school schedule, I would:

____________________________________________________________________________________________________________

My main occupation has been: ______________________________ Years of experience: _____________

List your last three jobs, beginning with the most recent:

Employer Name

Job Title & Specific Duties

Start

End

Reason Not Working

I have answered these questions to get unemployment benefits. I understand this information may be verified and that I must

promptly report any changes in the above conditions to the Unemployment Claims TeleCenter. I authorize the school, training

facility and/or my counselor to release information to the Employment Security Department about my enrollment, participation in

training, attendance and progress in the training.

Signature ___________________________________________________ Date ______________________

Phone _______________________ E-mail Address (Optional) ___________________________________

Student Eligibility Questionnaire Form - State Of Washington - Employment Security Department Page 3