Unemployment Insurance Form - Arkansas

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APPLICATION FOR UNEMPLOYMENT
INSURANCE BENEFITS
STATE OF ARKANSAS
DEPARTMENT OF WORKFORCE SERVICES
CLAIMANT INFORMATION
(*Information Fields Must Be Completed)
TODAY'S DATE: *SOCIAL SECURITY NUMBER: EFFECTIVE DATE: (Local Office Only)
*Have you filed an unemployment claim in another state in the last 12 months? (Other than Arkansas) Yes No *If yes which State?:
*FIRST NAME: MIDDLE INITIAL: *LAST NAME:
Mailing Address: *ADDRESS - Line 1: ADDRESS - Line 2:
*CITY: *State: *Zip:
Physical Address (if different than above): ADDRESS - Line 1: ADDRESS - Line 2:
CITY: Zip:
*State of Residence: *County of Residence: E-Mail Addr:
HOME PHONE: ( )
MOBILE: ( )
MESSAGE ONLY: ( )
*DATE OF BIRTH:
*GENDER: Male Female
*YEARS OF EDUCATION:
*ETHNICITY:
1-White-Non Hispanic 2-Black-Non Hispanic 3-Hispanic
(RACE) 4-American Indian or American Native 5-Asian Pacific Islander 6-Other
Are you handicapped (disabled)? Yes No
*Are you a citizen of the United States?
Yes No
If not a citizen, were you legally authorized to work in
the United States during the past 18 months?
Yes No
If yes, Permit Number:
* Have you worked in another state(s) within the
past 18 months?
Yes No
If yes, List States:
LAST EMPLOYER INFORMATION (Current Employer if working - or - if not working, last employer)
*EMPLOYER NAME: ACCOUNT NUMBER:
(Local Office Only) UNIT NUMBER: (Local Office Only)
*STREET NAME:
*CITY: *STATE: *COUNTY: *ZIP CODE:
EMPLOYER PHONE: ( ) ORIGINAL HIRE DATE: DATE LAST WORK ENDED:
Are you scheduled to return to work or start a new job within 10 weeks?
Yes No
If yes date you are scheduled to return to work:
*Was your last work?
1-Full time (40 hrs) 2-Part time (less than 40 hrs) 3-Temporary (120 days or less)
*Type of separation:
Laid Off: Quit: Discharged: School Employee: Other:
Weather Personal Emergency Sleeping Spring Break Suspension Medical Leave
Lack Of Work Health Fighting Summer Break Shared Work Strike
Finished Job General Absent/Tardy Holiday Vacation Holidays
Business Closed Insubordination Lockout Still Working Part time
Drinking/Drug Test Family Medical Leave
General Reduced from full time (40 hrs)
Have you worked for an Educational Institution within the last 18 months? Yes No
If Yes, Were you laid off with reasonable assurance of recall the next semester?
Yes No
If No, Are you on a holiday recess or spring break with reasonable assurance of recall following the holiday or spring break?
Yes No
How did you get your last job?
1-Employment Security 2-In Person 3-Correspondence 4-Phone
5-Union 6-Other 7-Temporary Agency
What kind of work did you do on your last job?:
What was your rate of pay on your last job? $ Per
Hour Day Week Semi-Monthly Monthly
What hours did you work? From: AM PM To: AM PM
DWS-ARK-501 Page 1 of 2 (Rev. 11-04) CONTINUE ON REVERSE SIDE
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Unemployment Insurance Form - Arkansas PDF

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