Work Search Log printable pdf download

AMPSHIRE

MPLOYMENT

ECURITY

45 S

OUTH

RUIT

TREET

, NH 03301-4857

ONCORD

Work Search Log

Your Name____________________________ Social Security__________________

Please Print

PLEASE READ THE FOLLOWING INSTRUCTIONS:

If you have returned to full-time work, please see the “Returned to Work” section at the

bottom of this page.

To be eligible for unemployment benefits, you must be actively seeking work which you are qualified

to perform. It is your responsibility to keep a daily record of the employers you contact in search of

work. The other side of this form will help you keep a record of the employers you contact.

When filing your weekly continued claim or request for benefits, enter all contacts you

have made for the week. Periodically, you may be required to report to the local office to review

your work search efforts. In addition to reviewing the contacts you reported on your weekly claim,

please bring any work search logs you have collected for review.

Failure to provide an accurate record of your work search efforts and/or failure to report

to your local office when directed may result in your being disqualified from receiving

benefits. You would also be required to repay any benefits previously paid to you.

Returned to Work: If you have returned to full time work, please

complete the information below and send this form to the address

above:

Start Work Date:

___________________________________

Employer Name:

___________________________________

Employer Address: ___________________________________

___________________________________

If you have any questions regarding your claim or the use of this form, please call 603-223-6110.

NHES is a proud member of America's Workforce Network and NH WORKS.

NHES is an Equal Opportunity Employer and complies with the Americans with Disabilities Act.

Auxiliary aids and services are available upon request of individuals with disabilities. TDD ACCESS: RELAY NH 1-800-735-2964.

NHES 0162

R-5/14

Work Search Log