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NMON-2000

* Required Information


1. * Claimant SSN             --
2. * Claimant First Name            
3. * Claimant Last Name            
4. * Are you reporting a separation issue?             Yes No
If Yes, provide the separation information            
a. Separation Reason            
b. Separation Date            
 /  /  
c. Separation Details
(Must not exceed 256 characters.)
           
5. * Are you reporting a Refusal of work?             Yes No
a. If Yes, provide the date of refusal            
 /  /  
6. * Employer Information            
a. Mississippi Employer Account Number             ---
b. Submitter Name            
c. Submitter Title            
d. Phone             --