MISSOURI DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS

ELIGIBILITY ASSESSMENT

1. Have you worked since you filed for unemployment insurance benefits? This includes full-time work, part-time work, or temporary work. c Yes c No If Yes, provide dates of employment. Beginning Employment Date: Ending Employment Date: 2. Please provide your rate of pay on your last job. Hourly wage: $ or Salary: $ c Weekly c Monthly 3. How much experience did you have on that job? (check one) c Less than 6 months c 6 months – 1 year c 1 year – 3 years c 3 years – 5 years c 5+ years 4. Are you looking for: c Full-time work c Part-time work c Both 5. What type of work are you seeking?

c Construction c Retail c Office Services c Management c Manufacturing c Transportation c Health Care c Other 6. What days are you available for work? (check all that apply) c Sunday c Monday c Tuesday c Wednesday c Thursday c Friday c Saturday 7. What hours are you available for work?

From: c a.m. c p.m. To: c a.m. c p.m. 8. What is the lowest pay you will accept for work? Hourly wage: $ or Salary: $ c Weekly c Monthly 9. What type of transportation do you have to get to a job? (check one) c Private Vehicle c Public Transportation c Family/Friend c None c Other 10. How many miles are you willing to travel to a job (one way)? (check one) c 0-5 miles c 5-10 miles c 10-20 miles c 20-30 miles c More 11. Do you attend or plan to attend school or training? c Yes c No If currently attending school or training, provide name of educational or training institution: 12. Are you self-employed? c Yes c No

If Yes, please provide the number of hours worked per week. hours worked per week. 13. Do you have limitations that may keep you from performing the type of work that you are seeking? c Yes c No If Yes, please explain. 14. Do you have dependents who require care during work hours? c Yes c No If Yes, will you be able to make arrangements for the dependents if you are offered work? c Yes c No Name Date MODES-4633 (01-20)

Benefits

MISSOURI DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS WORK SEARCH RECORD

Name Social Security Number

XXX-XX-

Keep a list of all the employers and labor unions you contact each week while claiming unemployment benefits. Make at least as many contacts each week as you were instructed when you first filed. You must bring your completed Work Search Record with you when you report for your Reemployment Services and Eligibility Assessment interview. You can get additional copies of this form by visiting: labor.mo.gov/sites/default/files/pubs_forms/4633-AI.pdf or you may use your own sheet.

Date of

Contact

Employer's Name

Address, and Phone

Number

Method

of

Contact*

Name/Title of

Person Contacted

Position

Applied For

Was

Application

Taken?

Result of

Contact

1-25-16 ABC Company - 829 Juniper

Kansas City, MO 64111

816-***-****

T Eric Dean, Manager Warehouse Yes Check back

in Feb.

*T-Telephone P-In Person R-Sent Resume I-Internet

Missouri Division of Employment Security is an equal opportunity employer/program. Auxiliary aids and services are available upon request to individuals with disabilities. TDD/TTY: 800-***-**** Relay Missouri: 711 MODES-4633-2 (01-20)

IMPORTANT: If needed, call 573-***-**** for assistance in the translation and understanding of the information in this document.

IMPORTANTE!: Si es necesario, llame al 573-***-**** para asistencia en la traducción y entendimiento de la información en este documento.

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