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


Insert Dollar Amount ($)

Days of the Week / Hours of the Day

Please provide additional details:

First and Last Name

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