Please print this form.

Request For Unemployment Stamp

I, _____________________________________________________ am requesting an Unemployment stamp for
 

The Month of ______________________________, in the year of _____________________.

 

·         I was: (circle one)        On Medical Leave                   On Personal Leave                  Voluntary Lay-Off

 

·         I was OFF from work from:      (Month)__________       (Day)__________           (Year)__________

 

·         I will RETURN to work on:        (Month)__________       (Day)__________           (Year)__________  

I am / was Employed By: _________________________________________________
                          (Specify, Example Maysteel Allenton)

Name:  ___________________________________________

Address:  _______________________________________________         Apartment # _______________

City: ____________________________                   State: ___________   Zip Code _________________

To the best of my knowledge this information is true and correct. 

  Signature: ___________________________________________ Today’s Date: _____________________

                                           (Required)

**Dues must be paid in full for the prior month, regardless if last day worked was the 1^st or 31^st.

**It is necessary that you attach any relevant documents that may support the dates for which you are requesting an Unemployment Stamp. Ex. Copy of check stub, doctors excuse etc., **