GEORGIA DEPARTMENT OF LABOR (GDOL) WEEKLY WORK SEARCH RECORD Name (please print):__________________________________________ Social Security Number: _______________________________ You must make at least three new job contacts each week. You are required to keep a detailed record of your work search activities and submit evidence of three verifiable contacts as a part of your weekly certification. A claim week begins on Sunday and ends on Saturday at midnight. Your work search efforts are subject to audit by GDOL. Failure to submit a completed weekly work search record for any week claimed, or listing any unverifiable contacts, may result in a denial and/or repayment of benefits. Weekly work search records must be submitted by one of the following methods: Internet or fax. The faster, more preferred method is to submit by Internet. If you choose to fax your records, you must submit this form completed with your signature to one of the following numbers: 404-525-3605, 404-525-3606 or 1-877-302-1573 (toll-free). Other work search forms will not be accepted. We recommend you submit your work search immediately upon completing your weekly certification by Internet or Interactive Voice Response (IVR). For each week claimed, record your work search activity on this form, completing all of the required information. The contact information provided must correspond with the week claimed. Retain a copy of this form for your records. (Please fill in the information below) Report for the week of (Sunday): Contact Date Employer Name Employer Contact Information (address, phone, e-mail) Person Contacted (if applicable) Method of Contact through (Saturday): Type of Work Sought Results/Outcome CERTIFICATION STATEMENT: I certify all information I have provided on this form is true and correct. I understand the law provides severe penalties for any person making false statements or representation as to a material fact knowing the same to be false in order to receive benefits. A signature is required to be considered a completed record. _______________________________________________________________________ Claimant's Signature __________/_________/_____________ Date DOL-2798 (R-01/13) American LegalNet, Inc. www.FormsWorkFlow.com