REEMPLOYMENT AND ELIGIBILITY ASSESSMENT QUESTIONNAIRE
Complete the front and back of this form and bring it to your interview.
FAILURE TO ATTEND THIS APPOINTMENT MAY AFFECT YOUR ELIGIBILITY TO RECEIVE UNEMPLOYMENT
Name Social Security Number
1. List your usual occupation(s)
Length of Experience
Last rate of pay
2. Date you were last employed:
3. What type of work are you seeking?
4. Lowest Wage you will accept to start work: Hourly Weekly Monthly
5. What work shift(s) are you willing to accept?
6. What transportation will you use to and from work?
7. How much time are you willing to spend to travel to and from work?
8. In what areas/localities are you willing to accept work?
9. How many employers do you usually contact each week?
10. Are there any days during the week you will not or cannot work?
If yes, l