Please check each box to certify you agree to follow all program terms and conditions:
1. At least three employees will participate in the program.
2. Participating employees have been employed full-time for at least six months or part-time for at least a year
before the start of the plan. Please note, seasonal or temporary employees are not eligible for the Work Share
3. Weekly work hours and wages will be reduced by at least 20% and not more than 40% for participating
4. I am aware that participation in the Work Share program may have an adverse effect on my
Unemployment Insurance tax rate.
5. I will continue to provide health benefits under the same terms and conditions as when the affected employee
worked his/her usual weekly hours, unless health benefits change for all my employees.
6. I will continue to provide retirement benefits under a defined benefit plan or contributions under a defined
contribution plan under the same terms and conditions as when the affected employee worked his/her usual
weekly hours, unless retirement benefits change for all my employees.
7. I will provide paid vacation, holidays, and sick leave under the same terms and conditions as when the affected
employee worked his/her usual weekly hours of work.
8. I agree to furnish all reports and information necessary for proper administration of my Work Share plan.
9. I have provided all employees participating in my Work Share plan with the Initial Claim application (included in
the Work Share Application Packet).
10. I will notify the Employment Department immediately if there are any changes to the information on this plan
application or the plan participant list.
By clicking the Submit button below, I agree to abide by all state and federal unemployment laws and attest that
all information provided on this application is true and correct.
By signing this form electronically, I understand and acknowledge that this electronic signature has the same
meaning and validity as my handwritten signature. I further attest that I have signature authority with the
Authorized Signature: Title:
UI Special Programs Center
PO Box 14518 • Salem, Oregon • 97309
(1695 Revised 0117)
NOTE: Click the button below to attach this document to an email. Once you have done so, attach your
Participant List to the same email. Your application cannot be approved without your Participant List.
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For more information about the Work Share Program, including rules and laws related to the program, please visit www.OregonWorkShare.org
Date of Review:
FOR OFFICE USE ONLY
Reduced Weekly Hours:
Normal Weekly Hours:
Payroll wk end:
El Departmento de Empleo de Oregon es un programa que respeta la igualdad de opportunidades.
Disponemos de servicios o ayudasauxiliares, formatos alternos para personas con conocimiento limitadodel
ingles, a pedido y sin costo.Llame al 7-1-1 para asistencia gratuita TTY/TDD para personas con dificultades
auditivas. Obtenga acceso gratis en internetpor medio del siguiente sitio: www.sprintrelayonline.com.
Disclaimer: If you send this form via email, it may not be secure. If you do not utilize email encryption software we advise you contact the UI Special Program Center at (503) 947-1800 or (800) 436-6191 to sign up
with our secure email server. By clicking the submit button you acknowledge that you are responsible for ensuring the protection of the personally identifiable information included in this email.
The Oregon Employment Department is an equal opportunity employer/program. Auxiliary aids and
services, and alternate formats are available to individuals with disabilities and language services to
individuals with limited English proficiency free of cost upon request. TTY/TDD-dial 7-1-1 toll free relay
service. Access free online relay service at: www.sprintrelayonline.com.
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