Time Work Officer

Personal Information

Claimant Id: ********

Date of Birth: 09/29/1989 Other Last Name Used (1):

First Name: KIMBERLY Other Last Name Used (2):

Last Name: SHEPERD Other Last Name Used (3):

Middle Initial: L Gender: Female

Suffix: Mothers Maiden Name:

Address Information

Country: USA

Mailing Address, if different

from residential:

506 S GREEN STREET Mailing Address City: Selma

Mailing Address State: North Carolina Mailing Address Zip: 27576 Residential Address Country:USA

Residential Address: 9 ORIOLE COURTAPT I Residential Address City: Selma Residential Address State: North Carolina Residential Address Zip: 27576 Closest Employment

Services Office

NCWorks Career Center- Johnston County Commuter:

Contact Information

Primary Phone: 919-***-**** Ext : Alternate Phone: Ext: Cell Phone: Fax Number:

E-mail Address: adsxb3@r.postjobfree.com Preferred Contact Method: E-mail Demographic Information

Education Level: 14 - GED Disabled: No

Do you need an interpreter: No Veteran: No

Race: Black or African American U.S. Citizen: Yes

Ethnicity: Not Hispanic or Latino Alien Registration Number: Preferred Language: English

Eligibility

Indicate from what location you are filing your claim Home Have you applied for or are you receiving unemployment benefits from any other state or federal programs?

No

Employment Questions

Has all of your employment been in another state since 01/04/2020 ? No Has any of your employment been in another state since 01/04/2020 ? No Have you served in the Military since 07/04/2019 ? No Are you currently in the State of NC ?

Have you been employed as a civilian by the Federal Government since 07/04/2019 ? No Have you worked for a school or educational institution since 01/04/2020? Have you worked for a professional athletics organization since 01/04/2020 ? Are you a Longshoreman who has been assigned work by a Longshoreman union since 01/04/2020 ?

No

Are you an elected official ? No

Employability Questions

Are you currently self-employed or do you earn income on a commission basis? No Do you have plans to become self-employed or earn income on a commission basis? Are you currently able to look for, accept, and perform full time work for which you have training or experience?

Yes

Are you currently enrolled in school or in training? No Is there any other reason why you cannot seek or accept immediate work (such as child care, transportation, care of a family member, etc.)? Yes

Are you receiving or applying for benefits under a state or federal law based on a total disability?

No

Have you refused any work since you became unemployed? Employers - Regular

Employer Name Address Dates of Employment

Type of

Employment

EXECUTIVE PERSONNEL GROUP LLC, DBAEXECUTIVE

PERSONNEL GROUP LLC

PO BOX 1402 WASHINGTON

27889

05/12/2019-04/23/2020Full Time

Separation - Regular

Employer Name

EXECUTIVE PERSONNEL GROUP LLC,

DBAEXECUTIVE PERSONNEL GROUP LLC

Reason employment ended: A Layoff due to Coronavirus State where work was performed: North Carolina

City where work was performed: Smithfield

Primary Occupation with this employer: Timing Device Assemblers and Adjusters Were you or are you now a corporate officer of this employer? No What were your total earnings with this employer from Were you or are you now a spouse of a corporate officer of this employer? No Other Separation

Are you currently receiving workers compensation for a job related injury or illness? No Are you or will you receive pension or retirement pay (other than Social Security)? No Are you or will you receive vacation pay, severance pay, military accrued leave pay or other separation pay?

No

Have you applied for or are you receiving any type of disability pay? No If you are eligible to receive benefits, would you like Federal Income Tax withheld from your benefits?

No

If you are eligible to receive benefits, would you like State Income Tax withheld from your benefits?

No

Do you have a definite return to work date or will start a new jobfor an employer you have not told us about?

No

If yes, what is the name of the employer?

If yes, what is your return to work or start date? Preferred Payment Method Debit Card

Work Search

What is your lowest Rate of Pay you will accept for the type of work you are seeking? $10.00 per Hour Are you willing to work any day of the week customary to the occupation you are seeking? Yes Are you willing to work any shift customary to the occupation you are seeking? No What round trip distance will you travel to seek and accept work 25

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