Employment History Form

Document Information
  How to complete a fillable form.
Title Employment History Form

Used to provide your employment history for the past three years, including self-employment and volunteer work.

Please start with your most recent job and work backwards. Please list any gaps or interruptions in your work history.  If you were unemployed at any time, please explain why.  Did you apply for (or receive) unemployment benefits during the time period? If yes, what dates did you receive unemployment benefits?  Did you seek employment during the time period?  If no, why didn’t you seek employment?

Document number F242-109-000
How to get this document
  • Order it from our Warehouse
  • Alt Language(s) Español
    Valid dates 01/2006
    Contact information Claims for Job Injuries
    Websites Workers' Comp Claims

    End of main content, page footer follows.

    Access Washington official state portal

      © Washington State Dept. of Labor & Industries. Use of this site is subject to the laws of the state of Washington.