RETURN TO:
TN DEPT OF LABOR AND WORKFORCE DEVELOPMENT                          TENNESSEE DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT
EMPLOYER ACCOUNTS/EMPLOYER SERVICES                                               DIVISION OF EMPLOYMENT SECURITY
220 FRENCH LANDING DRIVE, 3-B
NASHVILLE, TN 37243
                                                                           APPLICATION FOR CLIENT NUMBER
(615) 741-2486       FAX (615) 741-7214                                  FOR CLIENTS OF A PROFESSIONAL EMPLOYER ORGANIZATION
                                                                                                            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 if different from above:     Client’s fax number:        _________________________
 ______________________________________________________________                 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 in Tennessee for 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 MUST BE FILED FOR EACH CALENDAR QUARTER IN WHICH WAGES WERE PAID.)
     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 MUST BE FILED FOR EACH CALENDAR QUARTER IN WHICH WAGES WERE PAID.)
     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 MUST BE FILED FOR EACH CALENDAR QUARTER IN WHICH WAGES WERE PAID.)
  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. 02-15)                                           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. 02-15)                                                 Page 2                                                                         RDA 1559