RETURN TO: 
TN DEPT OF LABOR AND WORKFORCE DEVELOPMENT                                          TENNESSEE DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT 
EMPLOYER ACCOUNTS/EMPLOYER SERVICES 
220 FRENCH LANDING DRIVE, 3-B                                                        APPLICATION FOR CLIENT NUMBER 
NASHVILLE, TN 37243                                                               FOR CLIENTS OF A PROFESSIONAL EMPLOYER ORGANIZATION 
(615) 741-2486       FAX (615) 741-7214 
EMAIL:  EMPLOYERSTATUS.RATES@TN.GOV 
                                                                                                           OFFICIAL USE ONLY 
1A. Enter Professional Employer Organization        (PEO) Information 
                                                                                   Tennessee ID Number            M.No.       County         Alt Zip 
PEO State No.                           - 
PEO Name             ____________________________________________                  Liab. Org.    First Employment                    Date Liable 
1B. Enter Client Company Information 
Client’s Federal  Number                  -                                         Comp Year             NAICS              M-NAICS            Verified 
Client’s Employer Name   ____________________________________                      
                           ____________________________________                                                    Rates 
Client’s Trade Name        ____________________________________ 
                           ____________________________________                    
Client’s Mailing Address   ____________________________________                    
                                                                                   Client’s company phone: 
                           ____________________________________                    
2. Client’s Physical Business Address in Tennessee(other than employee             Client’s fax number: 
residence)  if different from above:
                                                                                   Client’s email address:     
                                                                                   Client’s business website:  
3. CHECK (X) FORM OF ORGANIZATION             4. Name of Client Company’s Partners, Corporate Officers, Limited Liability Company        Social Security 
   OF CLIENT COMPANY                                Members and Managers (if Board Managed), General Partners                                Number 
                                                    (Attach separate sheet if necessary.) 
    † INDIVIDUAL                                __________________________________________________________________________ 
    † PARTNERSHIP                                   __________________________________________________________________________ 
    † CORPORATION                               __________________________________________________________________________ 
    † LIMITED LIABILITY COMPANY                    __________________________________________________________________________ 
    † LIMITED PARTNERSHIP                       __________________________________________________________________________ 
    † OTHER                                         __________________________________________________________________________ 
NOTE: If a Limited Liability Company, are you treated by IRS as a(n)      Individual Proprietorship            Partnership or as a       Corporation? 
5.Name of person responsible for payroll records                               †                        Phone Number †                   †
                                                                               †                                  †                      †
6.A. Number of workers your client has employed (will employ) in TN            †    D. Is your client presently†reporting for U.I. purposes†in another state?
                                                                               †         YES†NO †              If YES,†which state?      †
   B. Date your client first employed (will employ) a worker in TN                  
                                                                                    E. If your client is a corporation or LLC, provide formation information.
   C. Date your client first paid (will pay) a worker in Tennessee                       Date                      State      Control No.
7. NONPROFIT EMPLOYMENT(SEPARATE REPORTS MUST BE FILED FOR EACH CALENDAR QUARTER IN WHICH WAGES WERE PAID.)
   A. Is your client organization exempt from Federal Income Taxes under Section 501(c)(3) of the IRS Code? YES                          NO     †
      If YES, attach a copy of letter of exemption.                                                                           †              †
   B. Has your client employed or expects to employ four (4) or more individuals inTennesseefor any portion of a day within†twenty (20) different†   weeks
    in a calendar year?                   YES †          NO †                                                                 †              †
    If answer is YES, give month and year of the twentieth week of the first year this occurred.  MONTH                       † YEAR         †
8. REGULAR BUSINESS EMPLOYMENT(SEPARATE REPORTS MUSTBEFILEDFOREACHCALENDARQUARTER INWHICH                                            WAGES WEREPAID.)
   A. Has your client employed or does your client expect to employ at least one worker in twenty different calendar weeks during a calendar year?
    YES †             NO † If YES, give earliest month and year the twentieth week occurred (will occur). MONTH                          YEAR  
   B. Has your client had or does your client expect to have a quarterly payroll of $1,500 or more?   YES †            NO † 
      If YES, give earliest quarter and year this occurred (will occur).       QUARTER                             YEAR  
9. HOUSEHOLD EMPLOYMENT                 (SEPARATE REPORTS MUSTBEFILEDFOREACH CALENDAR QUARTER INWHICH                         WAGES WEREPAID.)
   A. Has your client had or does your client expect to have a $1,000 quarterly payroll for domestic services?  YES †            NO †
      If YES, give earliest quarter and year this occurred (will occur). QUARTER                                  YEAR  
10. AGRICULTURAL EMPLOYMENT (SEPARATE REPORTS MUSTBEFILEDFOREACH CALENDAR QUARTER INWHICH                                        WAGES WEREPAID.)
   A. Has your client employed or does your client expect to employ at least ten or more workers in some part of a day in twenty different weeks during a
      calendar year?  YES † NO †
      If YES, give earliest month and year this occurred (will occur). MONTH                     YEAR
   B. Has your client had or does your client expect to have a quarterly payroll of $20,000 or more?   YES †            NO †
      If YES, give earliest quarter and year this occurred (will occur). QUARTER                                   YEAR   
   C. Is all activity performed on a farm?   YES†   NO   †         If NO, what percentage is?                  Please explain in 11A on page 2. 
Client’s  Signature                                                      Title                                                Date 
LB-0910 (Rev. 09-19)                                      PLEASE COMPLETE PAGE 2.                                                                    RDA 1559 

Client’s Federal Number        - 

11. A. Describe the major business activity of the account to be covered, listing any products manufactured or sold, or service provided.
    Be as descriptive as possible. _____________________________________________________________________________                                      
    ______________________________________________________________________________________________________                                            
    ______________________________________________________________________________________________________                                            
    ______________________________________________________________________________________________________                                            
    ______________________________________________________________________________________________________                                            

    B. In what  Tennessee County   is your company located?
    (If account covers sales reps or other personnel working from home, list county or city of residence.)

    C.Is the primary purpose of the employee(s) covered by this application to support other locations of your company?

    YES †            NO † If YES, then check the category that best applies. Add comments as necessary. 
    †HEADQUARTERS  (e.g.,  corporate  or  regional  management  offices)                                                                      ___       
    †ADMINISTRATIVE (e.g., bookkeeping, accounting, payroll, HR, PR) _____________________________________________                            ___       
    †WAREHOUSING (e.g., storage, distribution, equipment yard)__________________________________________________                             ___       
    †SALESMAN (indicate product) _________________________________________________________________________                                   ___       
    †INFO TECH  (e.g.,  software  publication,  programming,  systems  design,  data  processing)    
    †OTHER (e.g., repair shop, security office,  maintenance,  employee  recreation  facility)                                                ___       
    D. Below are some industries that often need additional clarification.  This section may not apply to every employer.
    If you see your industry, please answer the corresponding question(s).

    Construction:          What type of construction? ______________________________________________________________                            ___ 
                           Mostly  residential or non-residential?                          †residential               †non-residential 

    Property Mgmt.:        Does this business manage property for others or for itself?                †others         †itself 
                           Mostly  residential or non-residential?                          †residential               †non-residential 

    Trucking:              Is the main trucking activity local or long distance?            †local                     †long distance 
                           Mostly truckload or less than truckload?                         †truckload                 †less than truckload 

    Employment Agency:  Is this a temporary staffing service or an employment placement agency? 
                           †Temporary Staffing Service                             †Employment Placement Agency 

    Health Care:           Is this a    †doctor’s office,    †multi-disciplinary clinic,    †freestanding urgent care center or     other?†  
                           Please specify.________________________________________________________________________  

    Info Tech (IT):        Which category best fits your business? 
                           †software publication      †programming                 †systems design        †data processing 

    Restaurant:            Is the restaurant    †full service,    †fast food,    †cafeteria/buffet,    †snack bar,    †other? 
                           Please specify. _______________________________________________________________________                             ___ 

    Consulting:            What is the primary type of consulting? 
                           †administrative, †human resources,           †marketing,         †process/logistics,  †environmental, or †other 
                           Please specify. _______________________________________________________________________ ___ 

    Home Health:           Does the care involve skilled nursing?            YES          †NO       †

    Retail:                   What is the primary product? ____________________________________________________________ ___ 

    Wholesale:             What is the primary product? ____________________________________________________________ ___ 

    Mining:                   What is the primary product? ____________________________________________________________ ___ 

    Convenience Store:     Does the store sell gasoline?                           YES          †NO †

    Manufacturing:         What is the primary product? ____________________________________________________________                         ___       

    LB-0910 (Rev. 09-19)                                                Page 2                                                              RDA 1559