State of Georgia Department of Labor
1. Employee's Name a. State any other name(s) under which employee worked. 3. Period of Last Employment: From 4. REASON FOR SEPARATION: a. LACK OF WORK b. If for other than lack of work, state fully and clearly the circumstances of the separation: To 2. S. S. No.
5. Employee received payment for: (Severance Pay, Separation Pay, Wages-In-Lieu of Notice,...
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