Fillable Work Share Application- Form 1695- 1.5.17

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Work Share Application- Form 1695- 1.5.17

On average this form takes 18 minutes to complete

The Work Share Application- Form 1695- 1.5.17 form is 2 pages long and contains:

  • 4 signatures
  • 10 check-boxes
  • 53 other fields

Country of origin: US
File type: PDF

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Please print or type the following information and complete all sections.
1. Employer Information:
a. Business Name:
d. Mailing Address:
City:
State: Zip Code:
e. Physical Address (If different from mailing):
City:
State:
Zip Code:
f. Business Identification Number (BIN):
2.
Employer Representative: Please identify two representatives from your business to coordinate with Work Share Program
Specialists for program enrollment and participation.
a. Primary Employer Representative:
b. Alternate Employer Representative:
Name:
Name:
Job Title: Job Title:
Email:
Email
Phone:
Ext:
Phone:
Ext:
3 a. Requested plan start date (Must be a Sunday): (month/day/year)
b. Estimated number of employees affected:
d.
Employer union-affiliation(s) information (if applicable): The employer’s Work Share plan must be approved by the
collective bargaining agent for each affected employee under a collective bargaining agreement.
Union:
Local:
Phone:
Ext:
Authorized Union Rep. Name:
Signature:
Union:
Local:
Phone:
Ext:
Authorized Union Rep. Name:
Signature:
c.
5.
How many layoffs will you avoid?
Oregon Employment Department
| www.Employment.Oregon.gov (1695 Revised 0117)
Health or retirement benefits will not be affected if work hours are reduced to less than normal weekly hours.
f. How do you plan to notify your employees of the Work Share plan?
Plans expire after one year.
Please /ŶŝƚŝĂů
Page 1 of 2
By signing below I approve the named employer applying for a
Work Share Plan. I further attest that I have signature authority
with the named union. If I am signing this form electronically, I
understand and acknowledge that this electronic signature has
the same meaning and validity as my handwritten signature.
By signing below I approve the named employer applying for a
Work Share Plan. I further attest that I have signature authority
with the named union. If I am signing this form electronically, I
understand and acknowledge that this electronic signature has
the same meaning and validity as my handwritten signature.
Date:
Date:
e.
Please describe how your business plans to implement the Work Share Program:
PROGRAM APPLICATION
c. Industry:
g. # of Employees:
4 a. Did you attend a Work Share Presentation?:
b. Was the presentation helpful?
b. How did you learn about Work Share?
Please note- by providing your email address you agree to receive emails from the Oregon Employment Department
I'd like to
N/A
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signature
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signature
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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
program.
3. Weekly work hours and wages will be reduced by at least 20% and not more than 40% for participating
employees.
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
named employer.
Authorized Signature: Title:
Print Name:
Date:
UI Special Programs Center
Email: oed_workshare@oregon.gov
PO Box 14518 • Salem, Oregon • 97309
www.Employment.Oregon.gov
(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.
Page 2 of 2
For more information about the Work Share Program, including rules and laws related to the program, please visit www.OregonWorkShare.org
Examiner:
Date of Review:
FOR OFFICE USE ONLY
Date Received:
Approved?:
If
denied, reason
:
Plan #:
Current Employer?
Reduced Weekly Hours:
Normal Weekly Hours:
Initials:
Start:
End:
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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Work Share Application- Form 1695- 1.5.17

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Completed 13 May 2020

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