Form 362 - Request For Hearing & Referral
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1
2FoR DepaRtment use onlY
Date _________ BYE _________ CESN ID ____________
Documents Attached
Faxed to UIC__________
Yes
No
Office of Administrative Hearings
PO Box 14020, Salem OR 97309-4020
Date to Hearings______________ CESN ID_____________
(503) 947-1515 Toll Free 1-888-577-2422
FAX (503) 947-1531 TDD/TTY 711
Documents Attached
Request FoR HeaRing & ReFeRRal
Claimant_________________________________
Social Security Number_________________________________
__________________________________________
_______________________
Address
Telephone Number
City
State
Zip
Check here if new address
Email Address ____________________________
Claimant Representative Name ____________________________ Telephone Number ________________________
Address____________________________________________
City
State
Zip
Employer Name ________________________________________ Telephone Number ________________________
________________________________________
_________________________
Address
Email address
City
State
Zip
Employer Representative Name ___________________________ Telephone Number _________________________
Address______________________________________________
City
State
Zip
:
Hearing requested by
Claimant
Employer
• • • • • • • information in this box must be completed by the party appealing the decision. • • • • • • • •
How many Administrative Decisions are being appealed?
List the Decision mailing dates:
I disagree with the decision because:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Hearings are held 8:00 am to 5:00 pm Pacific time, Monday through Friday.
I am not available for a hearing on the following day(s) or date(s)
________________________________________
and/or time(s) ________________________________________
I understand that I may have an attorney, or other person authorized by me, represent me at the hearing at my own
expense. If I choose to be represented, it is mY ResponsibilitY to pRomptlY notiFY tHe
Hearings section in writing tHat i aM rePresented.
If interpreter is needed,
Date Appeal Filed _______________________________________________ ____
please specify language:
_______________________
Requester's Signature ________________________________________________
special inFoRmation FoR
claimant:
to pRotect YouR RigHts while this appeal is pending, you must continue to file weekly claims while unemployed.
if you have a disability and need special accommodation in order to present your case, you may contact the office of
administrative Hearings at the numbers show above, between the hours of 8:00 am and 5:00 pm to discuss the
accommodation needed.
WorkSource Oregon • Employment Department •
Form 362 Front (0308)
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