Employer Reported Job Refusal

Use this employer form to report individuals who have:
• Refused an offer of work,
• Failed to report to work after hire, -OR-
• Have chosen not to return to work when recalled.


First and Last Name


No Dashes, Hyphens or Spaces






Position/Title








Insert Dollar Amount ($)


Days of the Week / Hours of the Day




Please provide additional details:






First and Last Name











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