Employment History Form {F242-109-000}

Department of Labor and Industries Claims Section PO Box 44291 Olympia WA 98504-4291 Worker's Name Page EMPLOYMENT HISTORY FORM of Claim Number Employment History Please provide your employment history for the past three years, including self-employment and volunteer work. Please start with your most recent job and work backwards. Please list any gaps or interruptions in your work history. If you were unemployed at any time, please explain why. Did you apply for (or receive) unemployment benefits during the time period? If yes, what dates did you receive unemployment benefits? Did you seek employment during the time period? If no, why didn't you seek employment? Please specify the MONTH and YEAR for dates. If additional space is needed, this form may be copied. From: Month / / / Year Month / / / To: Year Reason for work interruption Employer's Business Name Dates (month/year): From: / To: / _________ Wages: $ per: Hour Day Month City, State, Zip Code Did you receive any earnings other than wages? No Yes: $ per for: Employer's Phone Number Tips Piecework Bonuses Commissions ( ) ______________________________________________________ Did this employer contribute to your (or your family's) medical, dental, or vision insurance? No Yes Schedule: Did your employer pay or reimburse you for board, housing, fuel, or hours per day, days per week other such similar items? No What were your job title/job duties? Yes: Board Housing Fuel Other: ____________________ $ per Employer's Street Address Employer's Business Name Dates (month/year): From: / To: / _________ Wages: $ per: Hour Day Month City, State, Zip Code Did you receive any earnings other than wages? No Yes: $ per for: Employer's Phone Number Tips Piecework Bonuses Commissions ( ) ______________________________________________________ Did this employer contribute to your (or your family's) medical, dental, or vision insurance? No Yes: Schedule: Did your employer pay or reimburse you for board, housing, fuel, or hours per day, days per week other such similar items? No What were your job title/job duties? Yes: Board Housing Fuel Other: ____________________ $ per Employer's Street Address I certify that this information is true and correct to the best of my knowledge and belief. Date Signature F242-109-000 employment history form 1-06 Index: IW American LegalNet, Inc. www.USCourtForms.com