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Employee's Name2. S. S. No.AddressEmployer'sName(Street or RFD)CityStateZIP CodeTelephone No.NOTICE TO EMPLOYERNOTICE TO EMPLOYEEOCGA SECTION 34-8-190(c) OF THE EMPLOYMENT SECURITY LAW REQUIRES THAT YOU TAKE THIS. NOTICE TO THE GEORGIA DEPARTMENT OF LABOR FIELD SERVICE OFFICE IF YOU FILE A CLAIM. FOR UNEMPLOYMENT INSURANCE BENEFITS. SEE REVERSE SIDE FOR ADDITIONAL INFORMATION. DOL-800 (R-5/99)I CERTIFY that the above worker has been separated from work and. the information furnished hereon is true and employee correct.