Return completed form by mail to: Mississippi Department of Employment Security
P.O. Box 23088
Jackson, MS 39225-3088
Or return by fax to 601-321-6147 or by email to email@example.com
Claimant’s Name __________________________________________________________________________
Mailing Address ___________________________________________________________________________
Phone Number ____________________________________________________________________________
Email Address _____________________________________________________________________________
Business Name ____________________________________________________________________________
Business Address _________________________________________________________________________
This information is needed in order to make a decision about your eligibility for self-employment assistance beneﬁts.
Please provide the requested information. You may be required to provide additional information after your application
is reviewed. Providing false or misleading information may result in disqualiﬁcation of eligibility or a denial of beneﬁts in
accordance with Mississippi Department of Employment Security unemployment insurance laws.
1. What business are you going to pursue? ___________________________________________________
2. Do you have a patented product or copyright?
If yes, what is the product: ______________________________________________________________
3. Have you attempted to start a business before?
If yes, what type business: ______________________________________________________________
Was this business a success?
4. Do you already have a business?
5. Is your business registered with MDES?
6. Do you have a business license or certiﬁcate?
Application of Self-Employment Assistance Program (SEAP)
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