REEMPLOYMENT SERVICES AND ELIGIBILITY ASSESSMENT (RESEA) QUESTIONNAIRE Complete the front and back of this form and bring it to your appointment. FAILURE TO ATTEND THIS APPOINTMENT MAY AFFECT YOUR ELIGIBILITY TO RECEIVE UNEMPLOYMENT INSURANCE BENEFITS. Name 1. List your usual occupation(s) Social Security Number Length of Experience Last rate of pay 2. Date you were last employed: 3. 4. 5. 6. 7. 8. 9. What type of work are you seeking? Lowest wage you will accept to start work: Hourly What work shift(s) are you willing to accept? What transportation will you use to and from work? How much time are you willing to spend to travel to and from work? In what areas/localities are you willing to accept work? How many employers do you usually contact each week? Yes No Weekly Monthly 10. Are there any days during the week you will not or cannot work? If yes, list the days and the reason(s) you cannot work on these days. 11. Are you self-employed or plan to become self-employed? 12. Are you enrolled in or planning to enroll in school or training? 13a. If you are a union member, write the name and union number. Name No. 13b. Are you registered as out-of-work with your union? Yes Yes No No Yes No 13c. What does your union require you to do to be eligible for dispatch to work? 13d. Since your last job have you: (if yes to any question, write the date and explain) Yes No 1. Missed any roll call? Yes No 2. Been dispatched to a job? Yes No 3. Refused a dispatch to a job? Date: Explanation: COMPLETE THE WORK SEARCH QUESTIONNAIRE ON THE REVERSE DE 8531 Rev. 2 (9-16) (INTERNET) Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com CU WORK SEARCH QUESTIONNAIRE Name: Social Security Number: Complete the sections below listing the places you looked for work during the two weeks prior to this appointment date. Bring this completed form to your Reemployment Services and Eligibility Assessment (RESEA) appointment. Failure to look for work in any week may affect your eligibility to receive unemployment insurance benefits. WORK SEARCH RECORD Date applied Company name Company address Person contacted Type of contact (i.e. in person, phone, online) Type of work applied for Results (i.e., interview scheduled, job offered, etc.) I understand the questions on this form. I know the law provides penalties if I make false statements or withhold facts to receive benefits; my answers are true and correct. Signature: DE 8531 Rev. 2 (9-16) (INTERNET) Page 2 of 2 Date: American LegalNet, Inc. www.FormsWorkFlow.com