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GDOL use only.

Reviewed by:
RECORD OF WORK SEARCH

Georgia law (Section 34-8-195) requires you to look for work and be available for work
NAME
each week you claim unemployment benefits. How you look for work and the number of
contacts you make should depend on the type work you are seeking and the local labor
market. Keep a list of all job contacts. Take the list to the Career Center when you report
in person or mail it to the Career Center if requested. Your work search contacts may be SOCIAL SECURITY NUMBER
Name Date verified.

Date of Application or
Contact Name and Address of Company and Person Contacted Type of Work Method of Contact Results Resumé Filed?

 In Person  Not Hiring  Yes


 Telephone  Pending
 Mail, E-mail, or Fax  Hired  No
 In Person  Not Hiring  Yes
 Telephone  Pending
 Mail, E-mail, or Fax  Hired  No
 In Person  Not Hiring  Yes
 Telephone  Pending
 Mail, E-mail, or Fax  Hired  No
 In Person  Not Hiring  Yes
 Telephone  Pending
 Mail, E-mail, or Fax  Hired  No
 In Person  Not Hiring  Yes
 Telephone  Pending
 Mail, E-mail, or Fax  Hired  No
 In Person  Not Hiring  Yes
 Telephone  Pending
 Mail, E-mail, or Fax  Hired  No
 In Person  Not Hiring  Yes
 Telephone  Pending
 Mail, E-mail, or Fax  Hired  No
DOL-852 (R-11/03)
Date of Application or
Contact Name and Address of Company and Person Contacted Type of Work Method of Contact Results Resumé Filed?

 In Person  Not Hiring  Yes


 Telephone  Pending
 Mail, E-mail, or Fax  Hired  No
 In Person  Not Hiring  Yes
 Telephone  Pending
 Mail, E-mail, or Fax  Hired  No
 In Person  Not Hiring  Yes
 Telephone  Pending
 Mail, E-mail, or Fax  Hired  No
 In Person  Not Hiring  Yes
 Telephone  Pending
 Mail, E-mail, or Fax  Hired  No
 In Person  Not Hiring  Yes
 Telephone  Pending
 Mail, E-mail, or Fax  Hired  No
 In Person  Not Hiring  Yes
 Telephone  Pending
 Mail, E-mail, or Fax  Hired  No
 In Person  Not Hiring  Yes
 Telephone  Pending
 Mail, E-mail, or Fax  Hired  No
 In Person  Not Hiring  Yes
 Telephone  Pending
 Mail, E-mail, or Fax  Hired  No

I understand that failure to produce a list of my job contacts could result in loss of benefits. I understand that the law provides penalties for false statements for the purpose of
obtaining benefits.

Claimant’s Signature Date