DISTRICT OF COLUMBIA NEW HIRE REGISTRY
                                  Reporting Form

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 Registry
                                  P.O. Box 457
                                  Norwell, MA 02061
                                  FAX: 877-892-6388
                                  PHONE: 877-846-9523

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