Work Refusal Reporting Form Claimant Information Claimant Name * Address Line1 Address Line2 City State AA-Armed Forces (Americas) AE-Armed Forces (Europe) AP-Armed Forces (Pacific) AL-Alabama AK-Alaska AZ-Arizona AR-Arkansas AS-American Samoa CA-California CO-Colorado CT-Connecticut DC-District of Columbia DE-Delaware FL-Florida FM-Federated lsts of Micronesia GA-Georgia GU-Guam HI-Hawaii ID-Idaho IL-Illinois IN-Indiana IA-Iowa KS-Kansas KY-Kentucky LA-Louisiana ME-Maine MH-Marshall Islands MD-Maryland MA-Massachusetts MI-Michigan MN-Minnesota MS-Mississippi MO-Missouri MP-Northern Mariana Islands MT-Montana NE-Nebraska NV-Nevada NH-New Hampshire NJ-New Jersey NM-New Mexico NY-New York NC-North Carolina ND-North Dakota OH-Ohio OK-Oklahoma OR-Oregon PA-Pennsylvania PR-Puerto Rico PW-Palau RI-Rhode Island SC-South Carolina SD-South Dakota TN-Tennessee TX-Texas UT-Utah VT-Vermont VA-Virginia VI-Virgin Islands WA-Washington WV-West Virginia WI-Wisconsin WY-Wyoming Zip Phone # Claimant Birth Date (in MM/DD/YYYY format) Social Security # Employer Information Employer Name * (where work was offered) Address Line1 Address Line2 City State AA-Armed Forces (Americas) AE-Armed Forces (Europe) AP-Armed Forces (Pacific) AL-Alabama AK-Alaska AZ-Arizona AR-Arkansas AS-American Samoa CA-California CO-Colorado CT-Connecticut DC-District of Columbia DE-Delaware FL-Florida FM-Federated lsts of Micronesia GA-Georgia GU-Guam HI-Hawaii ID-Idaho IL-Illinois IN-Indiana IA-Iowa KS-Kansas KY-Kentucky LA-Louisiana ME-Maine MH-Marshall Islands MD-Maryland MA-Massachusetts MI-Michigan MN-Minnesota MS-Mississippi MO-Missouri MP-Northern Mariana Islands MT-Montana NE-Nebraska NV-Nevada NH-New Hampshire NJ-New Jersey NM-New Mexico NY-New York NC-North Carolina ND-North Dakota OH-Ohio OK-Oklahoma OR-Oregon PA-Pennsylvania PR-Puerto Rico PW-Palau RI-Rhode Island SC-South Carolina SD-South Dakota TN-Tennessee TX-Texas UT-Utah VT-Vermont VA-Virginia VI-Virgin Islands WA-Washington WV-West Virginia WI-Wisconsin WY-Wyoming Zip Phone # Representative * (who made the offer) Work Offer Date (date the offer of work was made in MM/DD/YYYY format) Job Begin Date (date the job was to begin in MM/DD/YYYY format) Rate of Pay Education Required Work Type Offered Job Type Permanent Temporary Hours of job offered Drug Test Required? Yes No If "Yes", did Claimant Pass or Fail Job Refuse Reason Any other information you feel is important for us to know to complete our investigation: (max. 4000 chars) Information Submitted by Full Name * Phone # Email
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