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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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