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 benets, 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 Benet 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 falsication 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 benets 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 benets.
UC-304 REV 08-18 (Page 1)
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