Employer Name: _______________________________________________________ Phone: ____________________________________
Address: __________________________________________________________________________________________________________
Date: ____________________________ Signature: (Of Company Representative) ____________________________________________
IF REPLYING BY EMAIL, TYPE YOUR EMAIL ADDRESS HERE.
Employee Name:
________________________________
Social Security Number:
________________________________
Date to Begin Work: _____________
Date Refused Job: ______________
1.
Employee Name:
________________________________
Social Security Number:
________________________________
Date to Begin Work: _____________
Date Refused Job: ______________
3.
Employee Name:
________________________________
Social Security Number:
________________________________
Date to Begin Work: _____________
Date Refused Job: ______________
2.
TO EMPLOYER: To assist in reducing unemployment insurance fraud and overpayments, please complete this card
and submit it online or mail it to the address listed below. Please make sure the card is submitted online or mailed the
same day that a new hire, rehire or job refusal was made.
NEW HIRE REpoRtINg
Click here to reply by email or return by mail to: Mississippi Department of Employment Security 1911 Arcadia Street Hattiesburg, MS 39401
