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BUSINESS REGISTRATION                         ATTN: EMPLOYER SERVICES                                                                              TELEPHONE: 802-828-4344       VERMONT EMPLOYER NUMBER
                                              P.O. BOX 488                                                                                         FAX: 802-828-4248
C-1 (12/21)                                   MONTPELIER, VERMONT 05601-0488
COMPLETE BOTH PAGES OF THIS FORM, AND RETURN WITHIN 10 DAYS                                                                                                               INCOMPLETE FORMS WILL
OR GO TO 'EMPLOYER ONLINE SERVICES' AT WWW.LABOR.VERMONT.GOV.                                                                                                                    DELAY REGISTRATION.

     YOU WILL BE INFORMED OF YOUR VERMONT UI LIABILITY

                                                                                                                                                           1. FEDERAL ID NUMBER

2. EMPLOYER'S LEGAL NAME                                                                                                                5. MAILING ADDRESS                 STREET

3. TRADE OR DBA NAME  (LIST ALL)                                                                                                        CITY                                      STATE              ZIP CODE

4. ATTENTION OR C/O NAME                                      5A. E-MAIL ADDRESS/WEB ADDRESS
                                                              5B. TELEPHONE NUMBER                                                                                         5C. FAX NUMBER
6. TYPE OF ORGANIZATION (CHECK ONE)            SOLE-PROPRIETORSHIP OR DOMESTIC                                                                     PARTNERSHIP                CO-OWNER (Husband/Wife or Civil Union Partners)
        501 (c)(3) CORPORATION, MUST ATTACH IRS EXEMPTION                                                                               ASSOCIATION                        TRUSTEE IN BANKRUPTCY
         LIMITED LIABILITY COMPANY (LLC/LLP/L3C)       CORPORATION, SPECIFY STATE AND DATE OF INCORPORATION ______________________________________________
6A.  LIST BELOW THE OWNER(S), PARTNERS, MEMBERS/MANAGERS OR OFFICERS:
  NAME                                                                                 SOCIAL SECURITY NO.                     TITLE                 HOME ADDRESS (NO P.O. BOXES)

                                                             MULTISTATE WORKERS
7. DO YOU HAVE EMPLOYEE(S) WHO WORKED FOR YOU IN ANOTHER STATE BEFORE WORKING IN VERMONT?                                                                                                        NO YES

7A. FIRST DATE OF EMPLOYMENT IN VERMONT: ______________________  DATE FIRST WAGES PAID IN VERMONT: _______________________
7B. HAS YOUR ORGANIZATION PAID FEDERAL UNEMPLOYMENT TAX ON WAGES PAID IN ANOTHER STATE IN PRIOR YEARS?                                                                 NO         YES, LIST YEARS
______________________________________________7C. ENTER THE NUMBER OF WORKERS FOR EACH WEEK AND THE TOTAL GROSS WAGES PAID FOR EACH CALENDAR QUARTER EMPLOYMENT OCCURRED.
      IF EMPLOYMENT OCCURRED PRIOR TO THE CALENDAR YEARS LISTED BELOW, PLEASE ATTACH ADDITIONAL SHEETS WITH THE NEEDED INFORMATION.
     DO NOT ESTIMATE FUTURE WAGES.     A WORKER IS ANYONE PERFORMING SERVICES FOR YOUR BUSINESS, UNLESS THEY ARE EXEMPT UNDER UNEMPLOYMENT.
CALENDAR YEAR 2022 - ENTER NUMBER OF WORKERS IN EACH WEEK                                                                                                                        ENTER QUARTERLY GROSS WAGES PAID
1-Jan       8-Jan    15-Jan   22-Jan   29-Jan    5-Feb 12-Feb 19-Feb                                                                  26-Feb 5-Mar 12-Mar  19-Mar   26-Mar

2-Apr       9-Apr    16-Apr   23-Apr   30-Apr    7-May 14-May 21-May                                                                  28-May 4-Jun 11-Jun  18-Jun   25-Jun

2-Jul       9-Jul    16-Jul   23-Jul   30-Jul    6-Aug 13-Aug 20-Aug                                                                  27-Aug 3-Sep 10-Sep  17-Sep   24-Sep

1-Oct       8-Oct 15-Oct     22-Oct    29-Oct    5-Nov 12-Nov 19-Nov                                                                  26-Nov 3-Dec 10-Dec  17-Dec   24-Dec       31-Dec

CALENDAR YEAR 2021 - ENTER NUMBER OF WORKERS IN EACH WEEK                                                                                                                        ENTER QUARTERLY GROSS WAGES PAID
2-Jan       9-Jan    16-Jan  23-Jan    30-Jan    6-Feb 13-Feb 20-Feb                                                                  27-Feb 6-Mar 13-Mar  20-Mar   27-Mar

3-Apr       10-Apr   17-Apr  24-Apr    1-May     8-May 15-May 22-May                                                                  29-May 5-Jun 12-Jun  19-Jun   26-Jun

3-Jul       10-Jul   17-Jul   24-Jul   30-Jul    7-Aug 14-Aug 21-Aug                                                                  28-Aug 4-Sep 11-Sep  18-Sep   25-Sep
2-Oct       9-Oct    16-Oct  23-Oct    30-Oct    6-Nov 13-Nov 20-Nov                                                                  27-Nov 4-Dec 11-Dec  18-Dec   25-Dec

                                                              DEPARTMENT USE ONLY
STATUS NAICS          COUNTY        TOWN   LMI NAICS           LIABLE                                                                  NO     YES   REPORTS DUE            NONE   EXAMINED BY        DATE
                                                              LIABLE
                                                              ESTAB                                                                                 IN UC                  MAIL  TICKLE DATE
LIAB CODE      TYPE     NEW                 ACS                        PREDECESSOR OR OLD NO.                                                                               RATES
                        RTA, SAME NO.       PARTIAL                    ______________________________
                        RTA, NEW NO.        FULL, TRANSFER EXPERIENCE
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8. VERMONT PHYSICAL LOCATION WHERE SERVICES ARE PERFORMED - STREET (NOT RFD OR P.O. BOX #)                                       TELEPHONE NUMBER

CITY                                                                   STATE                                       ZIP CODE      FAX NUMBER

9. DO YOU HAVE WORKERS PERFORMING SERVICES FOR YOUR BUSINESS WHOM YOU CONSIDER TO BE SELF-EMPLOYED OR INDEPENDENT CONTRACTORS?
     YES            NO  IF YES, PLEASE ATTACH A LIST PROVIDING NAME, ADDRESS, TELEPHONE AND TYPE OF SERVICE PROVIDED/PERFORMED.

10. DID YOU ACQUIRE THE ORGANIZATION, TRADE, BUSINESS OR ANY ASSETS OF ANY OTHER VERMONT EMPLOYER?
     YES - Complete items 11A-11F  and 12                NO, GO TO ITEM 12

DID YOU INCORPORATE YOUR VERMONT PROPRIETORSHIP OR PARTNERSHIP?                 YES - Account No.: __________________________

If YES, Complete items 11A-11F                      NO - Go to item 12

11A.  DID YOU ACQUIRE         ALL?          PART?    11B. DATE ACQUIRED __________________ 
11C. UNEMPLOYMENT ACCOUNT NUMBER OF BUSINESS ACQUIRED _________________
11D. NAME OF BUSINESS ACQUIRED _________________________________________________________________________________________________________________
11E. NUMBER OF EMPLOYEES RETAINED FROM FORMER OWNER               NONE               SOME               ALL        HOW MANY? ___________________________
11F. HOW WAS BUSINESS ACQUIRED? (check one)   PURCHASE                 MERGER   FRANCHISE                     ENTITY CHANGE
     LEASE (SPECIFY NATURE OF THE LEASE) ____________________________________________________________________________________________

12. HAVE YOU EVER HAD A VERMONT UNEMPLOYMENT ACCOUNT NUMBER FOR THIS BUSINESS OR ANY OTHER LEGAL BUSINESS ENTITY?
      YES       NO   IF YES, GIVE FULL BUSINESS NAME   ________________________________________________________________________________________________

                                              NATURE OF BUSINESS ACTIVITY
13A. PROVIDE A DETAILED DESCRIPTION OF THE NATURE OF ACTIVITY                  13B. LIST PRINCIPLE PRODUCT(S) OR SERVICE(S), IN ORDER OF
      IN VERMONT.                                                                                      IMPORTANCE.

13C. PLEASE SELECT THE APPROPRIATE CATEGORY BELOW WHICH CLOSELY DESCRIBES YOUR BUSINESS IN VERMONT. IF YOU HAVE
      MULTIPLE BUSINESS TYPES, PLEASE SPECIFY THE PERCENTAGES IN 13A. ABOVE.  PLEASE BE SURE TO PROVIDE DETAILS IN 13A AND 13B.
     Agriculture, Forestry, Fishing & Hunting          Transportation & Warehousing                                             Educational Services
     Mining                                            Information                                                              Health Care & Social Assistance
     Utilities                                         Finance & Insurance                                                      Arts, Entertainment & Recreation
     Construction                                      Real Estate & Rental & Leasing                                           Accommodation & Food Services
     Manufacturing                                     Professional, Scientific & Technical Services                            Other Services (Except Administrative)
     Wholesale Trade                                   Management of Companies & Enterprises                                    Public Administration
     Retail Trade                                      Administrative & Waste Services
     IF YOU ARE UNSURE OF THE CATEGORY IN WHICH YOUR BUSINESS FALLS, CONTACT LABOR MARKET INFORMATION AT (802) 828-3868 OR ACCESS THE WEB AT
     HTTP://WWW.NAICS.COM/SEARCH.HTM FOR MORE INFORMATION.

14. ENTER THE NUMBER OF ESTABLISHMENTS THE ABOVE BUSINESS OPERATES IN VERMONT                                     If more than ONE location, attach a list specifying each
INCLUDE: Home(s) of personnel, when the company does not have an office or worksite in Vermont.                   location with the STREET ADDRESS, CITY AND THE
EXCLUDE: Locations that are temporary (exist less than 1 year) or are not staffed on a regular basis.             NUMBER OF WORKERS AT EACH LOCATION.

15. The following information is necessary as future notices will be available electronically.  If the general contact is also responsible for UI Tax and Benefit
information, enter "Same" in those areas.

      UI General Contact*                                                    UI Tax Contact                                  UI Benefit Contact 
INTERNAL contact if other contacts fail:      Person/Service that completes UI Tax Returns                        Person/Service that completes separations/wage
                                                                                                                  requests      
E-MAIL*:______________________________        E-MAIL:______________________________                               E-MAIL:______________________________
* REQUIRED

16. SIGNATURE OF OWNER, PARTNER, OFFICER OF CORP., OR HEAD OF HOUSEHOLD                                TITLE                     DATE






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