Work Search Log Page 2
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2Week one: Week Ending: ________________
DATE
EMPLOYER(s) CONTACTED
METHOD OF
TYPE OF WORK
RESULTS
MO/DA/YR
Write Employer name and address below.
CONTACT
SOUGHT
Name:
Street:
City/Town:
State:
Phone:
Name:
Street:
City/Town:
State:
Phone:
Name:
Street:
City/Town:
State:
Phone:
Name:
Street:
City/Town:
State:
Phone:
Week two: Week ending: _________________
Date
EMPLOYER(s) CONTACTED
METHOD OF
TYPE OF WORK
RESULTS
MO/DA/YR
Write Employer name and address below.
CONTACT
SOUGHT
Name:
Street:
City/Town:
State:
Phone:
Name:
Street:
City/Town:
State:
Phone:
Name:
Street:
City/Town:
State:
Phone:
Name:
Street:
City/Town:
State:
Phone:
Indicate any other activities you did to find employment. List additional contacts on a separate piece of paper.
I HEREBY CERTIFY ALL INFORMATION PROVIDED ON THIS FORM REGARDING MY WORK SEARCH EFFORTS IS TRUE AND ACCURATE.
I UNDERSTAND THERE ARE PENALTIES FOR WILLFULLY PROVIDING FALSE INFORMATION.
______________________
_____________________________ _____________________
____________
Claimant Name (Printed)
Claimant Signature
SSN
Today’s Date
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