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For Office Use Only |
| Petition No. Blank Space |
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Date FiledBlank Space |
| Field Office No. Blank Space |
Date of ApplicationBlank Space |
| Worker’s Name (Last, First, Middle)Blank Space |
Social Security No.
XXX-XX- Blank space |
Paying StateBlank Space |
| Address (No., Street, City or County, State, ZIP Code)Blank Space |
Daytime Phone #Blank Space |
Address For Check Mailing (No., St., City or County, State, ZIP Code)Blank Space |
| A. Worker Application for Relocation Allowances |
| 1. Were you totally separated from adversely affected employment? |
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2. Any other family member applying for relocation benefits?
If yes, give his/her name and SSN. |
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3. Are you currently employed?
(If “Yes,” complete the information concerning your present employment) |
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| Name and Address of FirmBlank Space |
Telephone Number of FirmBlank Space |
Date Employment Expected to EndBlank Space |
| Explain Why Employment is Ending:Blank Space |
4. Did relocation begin before filing a request for relocation allowances?
(If “Yes”, explain.) |
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5. Is this your first request for relocation allowances under the Trade Act of 1974?
(If “No”, explain.) |
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6. Have you or will you receive relocation allowances from any other source?
(If “Yes”, explain.) |
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| 7. Have you obtained suitable employment, or do you have a bona fide offer of employment in another area? |
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| Name and Address of Firm Offering EmploymentBlank Space |
Job Title Blank Space |
Starting DateBlank Space |
Expected Date of MoveBlank Space |
| City and State of RelocationBlank Space |
Employer’s Telephone No.Blank Space |
| B. Worker Request for Travel Allowances |