SOUTH CAROLINA DEPARTMENT OF EMPLOYMENT AND WORKFORCE EMPLOYERS REQUEST FOR
BENEFIT ADDRESS

*Account Number: *Employer Name:

FEIN: Trade Name:

C/O:

*Address:

*City: *State:

*Zip Code:

*Telephone Number:

Fax Number:

Email Address:

Benefit Consultant Name (if applicable):

Power of Attorney: Yes No
*If Yes attach copy of Power of Attorney

*Contact Name:

*Contact Telephone Number:

*Signature: Title:

Return To: SCDEW
*Required Fields Attn: Employer Status
PO Box 995 UCE-101BA Columbia, SC 29202 Rev. June 2010 Catalog#: 08989

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