Georgia New Hire Reporting Form 
  Federaland state  legisatl ion (Georgaistatute 19- 1-92)1 .  ,requi  resallGeorgai      employers,      both public and priva  te, 
  toreporttothe New H    ire ReportingProg   r.am allnewylh   ired,reh   ired  ,orreturn  ingtoworkempoyeesl          . Informatoni
  about new hire reporting and   onlien reporting is available on   ourwebsite:wwwGA.            - newhire.com 
Send completed      forms to:                                       To ensure  e th h hig est elve ol  f accuracy, plense printneatly In 
                                                                    capi tal lettersandavoidcontact with the edg      es of the boxes. 
Geo rgai NewHire    R·eportingCenter                                The  follow ni g will serve as an exampl   e: 
PO Box 3068    Tre nton, NJ 08619-0068 
Faxtoll-free:(888) 541-0521or (404)525-2983                              I1      I2    I3      I          ,..-A""'l-B....-C.. 

                                            EMPLOY       ER INFOR M        ATION 
FederalEmp oyerl   ID Number(FEIN):(Pl     eauen  terthesame     FENI   usedtoreporttheemployee's            quarte yrl  wages) 
I  I  1 1 -  I  I  I           I      I  I  I 
Employer Name  : 

EmployerCil                                                                                 State:           Zpi   Code: 
I  I  I                                                                                    Ir      I         I  I  I 
Contact Name: 

EmployerPhone:                                        Extensio   n:               Employer    Fax   :(optional} 
I  I  I I                                                I     I                 I  I      I       I  I  I 
Email Address: 
                                                               I 

                                             EMPLO EEY      INFORMATION 
Empoyeel Socia   l Security Number   (SSN): 

........____,J ~ I    I    1-1  I          I 
Emf'oyee First Name:                                                                                                    Middl eIni itla : 

I       I   I  I  I                                                                                                          D 
Employee Last  Name   : 
I  I  I  I  I  I                                                                                                      I 
Empoyeel Address: 

I I  I  I I                                                                                                             I               I · 
Employee City:                                                                              State:           Zip Code: 
I  I    I  I                                                                               I  I              I     I    I
Start Date(MMDDVYr                Date ofBirth:                         Medi   cal Insurance     Available:  (opti onal) 
I  I  I  I  I                  I  I  I  I                                           ves O  ONo 
Medcai Insurancel Company     Name:(optional) 
11111111111 
                                                                                                                     RevDiite:·02/ 24/17 
                                  Rep>0rts mustbesubmitted  within 10 daysof hrieorreh ire date. 
                              REPORTS WILL NOirBE PRO  CESSED IF REQUIRED jNFORMAJ!ON ISM        ISSING 
                                 Questions? Callus toll-freeat(888} 541·0469  or (404) 525-2985