Required
Employee Information |
Required Employer Information |
Employee's
full name |
Employer's name (please use corporate name) |
(Please
identify first, middle, and last name) |
Employee's
address |
Employer's address (please
provide address where Income Withholding Orders should be sent.) |
Employee's
Social Security Number |
Employer's Federal Employer
Identification Number (FEIN). If you have more than one FEIN, please make
certain you use the same FEIN you use to report your quarterly wage
information when reporting new hires. |
Employee's
date of hire |
Reemployment assistance
identification number (if applicable) |
Employee's
state of hire (only if reporting as a multistate employer) |
|
|
|
Optional
Employee Information |
Optional Employer Information |
Employee's
date of birth |
Employer's phone number |
Employee's
state of hire |
Employer's fax number |
|
Employer's email address |
|
Employer’s contact (individual’s
name) |
|
Medical insurance availability |