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

twc.state.tx.us

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

INSTRUCTIONS

Name

SSN

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

On or Offshore Worker

Name of Company Official Contacted

Position of Company Official

Telephone Number of Official

Date

Staff Signature

Last name, First name, MI

Social Security Number

Petition Certification Number from TWIST Group

Actions

Identify the certified petition name and location

Identify the division if certification is limited by

division

Home address of worker

Title of job held by worker at the time of separation

The division of the company that the worker was

employed with at the time of separation if

certification is limited by division

Last day worker physically on the job

Last day wages received for actual work performed

Name of location where worker performed his or her

last job (City/Town)

State the complete reason for the separation

Involuntary if separation initiated by employer;

voluntary is initiated by worker

Identify the State where wages were reported

If offshore worker, identify the shore from which

worker separated

Identify who at the company provided the

information

Position of the person who provided the information

Phone number of the person who provided the

information

Date staff completed the form

Signature of staff submitting the information

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

Forms Appendix F-400

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