RETURN TO:
TN DEPT OF LABOR AND WORKFORCE DEVELOPMENT EMPLOYER SERVICES (STATUS/RATES) 220 FRENCH LANDING DRIVE NASHVILLE, TN 37243 (615) 741-2486 FAX (615) 741-7214
TENNESSEE DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT DIVISION OF EMPLOYMENT SECURITY
APPLICATION FOR CLIENT NUMBER
___
Tennessee ID# OFFICIAL USE ONLY M. No. SIC County Area
1A. Enter Staff Leasing Company Information Staff Leasing Co. State No. ___ ___ ___ ___ - ___ ___ ___
Staff Leasing Co. Name _________________________________ 1B. Enter Client Company Information Client's Federal Number ___ ___ - ___ ___ ___ ___ ___ ___ ___ Client's Employer Name _________________________________ Client's Trade Name _________________________________ Client's Mailing Address ________________________________ ___________________________________________________
Liab. Org.
First Employment
Date Liable
Rate
Comp Year
NAICS
M-NAICS
M-SIC
Previous No.
ROC
AUX-SIC
VERIFIED
2. Client's PHYSICAL BUSINESS ADDRESS in Tennessee if different from above: CLIENT'S COMPANY PHONE: ( _____ ) _____________ ________________________________________________________________ ________________________________________________________________ CLIENT'S FAX NUMBER: ( ______ ) ________________ ________________________________________________________________ CLIENT'S E-MAIL ADDRESS: __________________________________ NOTE: If client organization is exempt from Federal Income Taxes under Section 501(c)(3) of the IRS Code, attach a copy of letter of exemption.
3. CHECK (X) FORM OF ORGANIZATION
OF CLIENT COMPANY INDIVIDUAL PARTNERSHIP CORPORATION LIMITED LIABILITY COMPANY LIMITED PARTNERSHIP OTHER
4. Name of Client Company's Partners, Corporate
Officers, Limited Liability Company Members, and Managers (if Board Managed), General Partners (Attach separate sheet if necessary)
Social Security Number
Residential Address and Phone
NOTE: If client is a Limited Liabilty Company, are you treated by IRS as a(n)
Individual Proprietorship
Partnership or as a
Corporation
5. Name of person responsible for payroll records _____________________________________ 6. A. Number of client's workers in Tennessee __________
Phone Number _______________________
B. Date client's workers first employed by staff leasing company in Tennessee ____/____/____
C. Date client's workers first paid by staff leasing company in Tennessee ____/____/____ 7. Briefly describe the major business activity of the client company's account to be covered, listing any products produced or sold, or service provided. Be as descriptive as possible. ___________________________________________________________________________________
__________________________________________________________________________________________________________
In what Tennessee County is the client company located? __________________________________________________________________________ (If account covers sales reps or other personnel working from home, list county of residence. If county is unknown, list city of residence.)
For the work location covered by this application, is the main activity to: (Check one)
Supply products and services to the general public or other companies Support other locations of the client company (if you check this, please specify below) HEADQUARTERS (e.g. : Corporate or regional management offices) ADMINISTRATIVE, OTHER THAN HEADQUARTERS (e.g.: data processing, public relations) RESEARCH (e.g.: R & D, product testing, laboratory) STORAGE (e.g.: warehouse, distribution center, equipment yard) OTHER (please describe) (e.g.: Repair shop, security office, maintenance, employee recreation facility) _______________________________ Please check the box describing client company's major business activity:
Agriculture, Forestry, Fishing, Hunting Mining Utilities Construction Manufacturing Wholesale Trade Retail Trade Transportation and Warehousing Information Finance and Insurance Real Estate and Rental and Leasing Professional, Scientific, Technical Services Management of Companies and Enterprises Administrative and Support Services Waste Mgt. and Remediation Services Educational Services Health Care and Social Assistance Arts, Entertainment and Recreation Accommodation and Food Services Other Services __________________ _______________________________ Public Administration
Client Company Signature _________________________________________
LB-0910 (Rev. 05-08)
Title ___________________________
Date _____/_____/_____