Integration of Trade Services for Dislocated Workers - Texas ...

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Integration of Trade Services for Dislocated Workers - Texas ...

TRADE ADJUSTMENT ASSISTANCE

MASTER RECORD OF INVESTIGATION

All separation information must be obtained from the employer.

Name of Trade-Affected Worker

_________________________

SSN of Trade-Affected Worker - -

Petition Number

Petition Name

Petition Division Name

Worker’s Mailing Address

Job Title

Division Employed In

Last Day Worked

Last Day Paid

Work Location

Reason for Separation:

Involuntary or Voluntary

State Wages Reported To

Onshore or Offshore Worker

Name of Company Official Contacted

Position of Company Official

_________________________

_________________________

_________________________

_________________________

_________________________

_________________________

_________________________

_________________________

_________________________

_________________________

_________________________

_________________________

_________________________

_________________________

_________________________

Telephone Number of Company Official ( ) - _

Date:

Staff Signature:

FAX COMPLETED FORM TO 512-936-0331, ATTN: MARGIE CLARK

MR1 – (0505)

MR1 – (0505)

Appendix F-400

Forms

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