Return completed form by mail to: Mississippi Department of Employment Security
SEAP Benefits
P.O. Box 23088
Jackson, MS 39225-3088
Or return by fax to 601-321-6147 or by email to
Claimants 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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7. With what occupation do you have the most experience? ___________________________________
8. How many years of experience do you have in this occupation? ______________________________
10. List your last three (3) jobs, beginning with the most recent below:
Application Certification
I certify that I am applying for approval with MDES to participate in SEAP. I understand that this
information may be verified and I must report any changes in the information listed above to the
Mississippi Department of Employment Security at 601-321-6463 within three (3) business days of
any changes. I understand that if I am contacted by MDES, I am expected to provide the accurate
I authorize any program/training provider/coach who is assisting me in starting my business to
release information to the Mississippi Department of Employment Security about my enrollment,
progress, and participation in the program/training or activities.
I understand that I must remain able and available and actively seeking work until I have received
notification from MDES that I am approved for SEAP.
I certify that this information is true and correct to the best of my knowledge.
Printed Name: _____________________________________________________________________________
Signature: ____________________________________________ Date: ____________________________
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An equal opportunity employer and program, MDES has auxiliary aids and services available upon request to those with disabilities. Those needing TTY assistance may
call 800-582-2233. Funded by the U.S. Department of Labor through the Mississippi Department of Employment Security. MDES 01/09/13
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