Form Ldol-Es 77 - Separation Notice Alleging Disqualification Page 2
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2FORM LDOL-ES 77 (R 5-98)
SEPARATION NOTICE ALLEGING DISQUALIFICATION
9.
10.
Phone - Area Code & No.
Employer Acct. No.
11.
12.
Address
Street/Box
City
State
Zip Code
14.
15.
13.
Date
Title
Signature
FILL OUT IN TRIPLICATE. MAIL ORIGINAL TO - Administrator, Louisiana Department of Labor, Post Office Box 94094, Baton Rouge,
La., 70804-9094 WITHIN 72 HOURS after separation. Give the employee copy to the worker with 72 hours and retain the employer copy
TO ORDER THIS FORM, CONTACT OUR AREA OFFICE NEAREST YOU OR CALL (504) 342-2811 OR 2861.
for your files.
Failure to submit this notice within the specified time limits may forfeit your right to appeal. It must be submitted within 72 hours
after the worker=s separation from employ.
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