DE 1101IBD Rev. 5 (5-21) (INTERNET) Page 2 of 13
UNEMPLOYMENT INSURANCE APPLICATION
Social Security number: – –
10. Do you have a Driver License issued to you by a
State/entity?
a) If yes, provide the name of the issuing State/entity
and your Driver License number.
If no, answer questions b-d:
b) Do you have an Identication Card issued to you
by a State/entity?
c) If yes, provide the name of the issuing State/entity
and your Identication Card number.
d) How do you look for work and, if you have work,
how do you get to work?
10. Yes No
a) Name of issuing State/entity:
Driver License Number:
If no, answer questions b-d:
b) Yes No
c) Name of issuing State/entity:
Identication Card Number:
d) Please Explain:
11. What is your telephone number?
a) If you are deaf, hard of hearing, or have a speech
disability and use TTY or California Relay to
communicate, check the appropriate box.
11. – –
a) TTY (Non-voice) California Relay Service
12. What is your mailing address?
(Include your city, State, and ZIP code)
12. Street: Apt.:
City:
State: ZIP Code:
13. Is your residence address the same as your mailing
address?
a) If no, enter your residence address. (Include your
city, State, ZIP code and apartment number.)
A residence address cannot be a P.O. Box. Please
provide a street address.
13. Yes No
a) Street: Apt.:
City:
State: ZIP Code:
14. If you do not live in California, what is the name of the
County in which you live?
14.
15. What race or ethnic group do you identify with? Check one of the following:
White Black not Hispanic Hispanic
Asian American Indian/Alaskan Native Chinese
Cambodian Filipino Other Pacic Islander
Guamanian Asian Indian Japanese
Korean Laotian Samoan
Vietnamese Hawaiian I choose not to answer
16. Do you have a disability? (A disability is a physical or
mental impairment that substantially limits one or more
life activities, such as caring for oneself, performing
manual tasks, walking, seeing, hearing, speaking,
breathing, learning, or working.)
16. Yes No I choose not to answer
17. What is the highest grade of school you have completed? Check only one box.
Did not complete High School High School Diploma or GED Some college or vocational school
Associate of Arts Bachelor of Arts or Science Masters or Doctorate
18. Are you a Military Veteran?
18. Yes No
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