Self-Request For Records - Washington State Employment Security Department printable pdf download

Self-Request For Records - Washington State Employment Security Department

SELF-REQUEST FOR RECORDS

Immediately get your employment history information as far back as 2005

and most recent unemployment claim information on-line at

A response to this request will be sent within 10 TO 15 BUSINESS DAYS.

PROVIDE THE FOLLOWING INFORMATION:

Name (please include any alias or maiden name):

Social Security Number:

CHECK ONE OR MORE BOXES TO INDICATE THE RECORDS BEING REQUESTED:

I am requesting a copy of my Employment History from

through

(start date)

(end date)

I am requesting a copy of my Unemployment Payment History from

through

(start date)

(end date)

If you are seeking records other than the above (identify here):

AUTHORIZATION AND SIGNATURE:

a) Mail or Fax records to:

b) Send Request to:

Name:

Employment Security Department

Contact Phone #:

Attn: Records Disclosure Unit

Address Line:

P.O. Box 9046

City State Zip Code:

Olympia WA 98507-9046

Return Fax #:

Fax #

(866)610-9225

Phone # (360) 725-9440

c) I authorize the requested information/records be released and sent

to the entity identified in Section 3a.

d) By signing below I declare under the penalty of perjury under the

laws of the State of Washington that I am the individual whose

records are being requested.

______________________________________

________________________

Signature(Required)

Date

Rev. 11/15

Self-Request For Records - Washington State Employment Security Department