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LAST EMPLOYER'S REPORT OF APPLICANT'S SEPARATION
THE APPLICANT WAS EMPLOYED BY US AS A AT $ ?G_.PER (hour
w wEEK Monies)
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HE LAST WORKED ON EARNINGS (BEFORE DEDUCTIONS) DURING CALENDAR WEEK OF SEPARATION WERE $ 66.00
(MONTH DA YEAR)
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APPLICANT WAS SEPARATED 0 ( T AY YEAa)BECAUSE (PLEASE GIVE REASON IN DETAIL) - -
IF DISCHARGED, WAS CLAIMANT SO ADVISED WHEN HE WAS GIVEN HIS SEPARATION NOTICE ? YES ? NO Ir Y'5. By wwoM
PLEASE CHECK IF PERTINENT ? 1 WISH TO BE PRESENT WHEN APPLICANT IS INTERVIEWED REGARDING THE SEPARATION.
? TEMPORARY LAYOFF, WILL BE CALLED FOR WORK ABOUT (DATE)
? WE NOW HAVE WORK FOR THIS INDIVIDUAL.
? THE INDIVIDUAL HAS RETURNED TO WORK ON (DATE) - ,
? APPLICANT WAS NOT IN OUR EMPLOY.
DATE OF MAILING Nov, 1.3s 192 19 -
. EMPLOYER COPY
PLEASE RETURN THE
NAME OF FIRM Jeff. Co. Dept. of Hi,lhways
- OTHER
COPY ONLY ADDRESS Courthouse
Port'Tocnsend, Wash. 90368
NATURE AND TITLE) Clerk
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SIG
RCW 50.35.030 OF LAWS RELATING TO EMPLOYMENT SECURITY PROVIDE
"Employing units or agents thereof supplying information to the Employment Security Department pertaining to the cause of a benefit
claimant's separation from work, which use stated to the Department is contrary to fj given the benefit claimant by such employing
shall ilty of a misdemeanor and shall be punished
ing unit's employ
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unit or agent thereof at the time o
by a fine of not less than $20 nor more than $250 or by imprisonment in the county jail for not more than 90 days."
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