DEPARTMENT OF LABOR & INDUSTRY
OFFICE OF UNEMPLOYMENT COMPENSATION BENEFITS
WORK SEARCH RECORD
WORK SEARCH RECORD FOR WEEK BEGINNING SUNDAY THROUGH SATURDAY
To be eligible for UC benets, complete the work search record below. Refer to your Pennsylvania UC Handbook (Form UCP-1) or go to www.uc.pa.gov for complete
instructions or to print additional copies of this form.
If you are working part-time, and earning more than your Partial Benet Credit, initial here
JOB APPLICATIONS/INTERVIEWS WORK SEARCH ACTIVITY
#1
Date of Application or Date of Interview
Employer
Employer Contact Name
Employer Phone/Email
How did you apply for the job
Results
Date of Activity
Type of Activity
Location of Activity
Contact Name
Contact Phone/Email
#2
Date of Application or Date of Interview
Employer
Employer Contact Name
Employer Phone/Email
How did you apply for the job
Results
Date of Activity
Type of Activity
Location of Activity
Contact Name
Contact Phone/Email
#3
Date of Application or Date of Interview
Employer
Employer Contact Name
Employer Phone/Email
How did you apply for the job
Results
Date of Activity
Type of Activity
Location of Activity
Contact Name
Contact Phone/Email
EXEMPTION Employer/Hiring Hall Name Contact Name Contact Phone/Email
Written Date of Recall (attach copy)
Union Hiring Hall
I certify that all information I have provided in this document is correct and complete. I acknowledge that false statements in this document are punishable pursuant to
18 Pa.C.S. §4904, relating to unsworn falsication to authorities.
First Name M.I. Last Name Social Security Number XXX-XX- __ __ __ __ (last 4 digits)
Signature Date
A person who knowingly makes a false statement or knowingly withholds information to obtain UC benets commits a criminal offense under Section 801 of the UC Law,
43 P.S. §871, and may be subject to a ne, imprisonment, restitution and loss of future benets.
UC-304 REV 08-18 (Page 1)
