Free 48335.pdf - Indiana

Client name:

JOB SEARCH VERIFICATION
State Form 48335 (7-97) / IMP 0022 Worker ID: Case number:

INSTRUCTIONS:

Please fill out the information below and return this form to the following address by _________________.

Thank you.

County Office of Family and Children

Address (street, number, city, state, ZIP)

Worker's name

Telephone number ( )

List below EVERY face-to-face contact you make with employers and any employment agencies. than once, fill in a line for each separate contact. Continue your list on the back of this form.

When you contact the same employer more

DO NOT ASK THE EMPLOYER TO SIGN
Date Employer's name, address, telephone number Name of the person with whom you talked Contact Filed Application Interview
What happened?

THE INFORMATION I HAVE GIVEN ON THIS FORM IS CORRECT AND COMPLETE TO THE BEST OF MY KNOWLEDGE.
Client's signature Date (month, day, year)

(see reverse)

Date

Employer's name, address, telephone number

Name of the person with whom you talked

Contact Filed Application Interview
What happened?