DISTRICT OF COLUMBIA NEW HIRE REGISTR
                                    Reporting For

To submit new hire reports online, please register at www.dc-newhire.com 

-Please Make All Entries in CAPS                  -All Required Items 1-7 and 12-22 MUST  Be Completed 
                                 EMPLOYER INFORMATION 
                             ITEMS 1-7 ARE REQUIRED INFORMATION 

1. Unemployment                                   2. Federal Employer 
Insurance Number                                  ID Number (FEIN)* 

3. Employer‘s Name 

4. Employer‘s  Address 

5. Employer‘s City                                6. State            7. Zip Code 
                                                  9. Employer‘s Fax ( ____ )  _____-________ 
8. Employer‘s  Telephone ( ____ )  _____-________ 

10. New Hire Contact Person 

11. New Hire Contact Person’s Email 
                                 EMPLOYEE INFORMATION 
                          ITEMS 12-22 ARE REQUIRED INFORMATION 

12. Social Security                 13. First Day of  Work for Pay 
Number (SSN)                                      (MM/DD/YYYY) 

14. Employee’s First Name 

15. Employee’s Middle Name 

16. Employee’s Last Name                                    17. Suffix (if  Applicable) 

18. Employee’s Home  Address 

19. Employee’s City                               20. State           21. Zip Code 
                                                            23. Employee Salary and Rate 
22. Employee’s Date of Birth 
                                                                      $_______._____ per ____________ 
(MM/DD/YYYY) 

24. Sex of Employee (circle one)      Male          Female 

25. Are Health Care Benefits  Available to the Employee? (circle one)          Yes         No 

Employer must submit data within 20 calendar days of the new employee’s first day of work to: 
                          District of Columbia New Hire Registr
                                    P.O. Box 457
                                    Norwell, MA 02061
                                    FAX: 877-892-638
                                    PHONE: 877-846-952

FOR ADDITIONAL COPIES PLEASE PHOTO THIS ORIGINAL OR VISIT WWW.DC-NEWHIRE.COM