Form ES-21c (07-05) ES-21c (07-05) Report of State Employment Service Office

United States of America
Railroad Retirement Board

Form Approved

OMB No. 3220-0057

REPORT OF STATE EMPLOYMENT SERVICE (PART B)

SS No.

Name

The applicant identified above is being directed to you for referral to suitable employment. Before the applicant

leaves your office, complete ltem 1 on the previous page and return only that page to the applicant.
A. Keep this page with the individual's application for employment. To notify us of what action was taken, check the
appropriate box below then go to ltem B.
NOTE: If you check
then go to ltem B.

(I)

'laced

(I),(2),(3),or (4),also enter the Employer, Location, Job Title, Duration, and Rate of Pay,

(2)

Refused

Referral

Failed to

to

(3)

(4)

Employer
Employer:

Location:

Job Title:

Duration:

Job
Refused
offer

(5)

Failed to
Respond to
Call-In

ate/

B. SES Representative's Signature, Date, and Stamp

SES Representative

Date of Action

SES Local Office Stamp

C. Return this page in the postage paid envelope provided to:
U.S. RAILROAD RETIREMENT BOARD

PAPERWORK REDUCTION ACTIPRIVACY ACT NOTICE
The Railroad Retirement Board (RRB) is authorized to collect the information on this form under section 5(b) of the Railroad
Unemployment Insurance Act. Although you are not required to furnish this information, your cooperation in doing so will assist the
RRB in determining the continued eligibility of the individual named on this form to receive unemployment benefits.
We estimate this form takes 1.5 minutes to complete, including the time needed for reviewing the instructions, getting the needed data,
and reviewing the completed form. Federal agencies may not conduct or sponsor, and respondents are not required to respond to, a
collection of information unless it displays a valid OMB number. If you wish, send comments regarding the accuracy of our estimate or
any other aspect of this form, including suggestions for reducing the completion time, to: Chief of Information Resources Management,
Railroad Retirement Board, 844 N. Rush Street, Chicago, IL 6061 1-2092.