Bls-3023-nca

BLS 3023 - NCA

Industry Verification Form, BLS 3023 NCA

Form Approved, O.M.B. No. 1220-0032

utana department of Labor and industry

In cooperation with the U.S. Department of Labor

13	This report is mandatory under section 320.5 of the Utana Unemployment Insurance Code and Section 320-1 Title 22 of the Utana Code of Regulations, and is authorized by law, 29 U.S.C. 2. Your cooperation is needed to make the results of this survey complete, accurate, and timely.
23	The questions on this form concern the work location(s) using the Unemployment Insurance account number 1234567890 IN UTANA.
RESIDENTIAL SERVICES Inc. Attn: Walter smith 1234 MAIN STREET, SUITE 300 SOMECITY UA 12345-1234
33	We need the name and direct mailing address for the business using this Unemployment Insurance account, regardless of who prepares this form. This information does not affect mailings for tax purposes. Are the name and mailing address shown in Item 2 correct for the business using this Unemployment Insurance account?  YES  NO Please print corrections or additions to the right of the printed address in Item 2.  Company permanently out of business OR MOVED OUT OF UTANA Enter date closed or moved: ___________________________SKIP to Item 9 on the back of this form.
43	In addition to your mailing address, please tell us where your business is physically located (street and number). The physical location address is the place where you conduct your business and receive deliveries, so it cannot be a Post Office Box or a rural route number. Our records show that this business in Utana is physically located at: 1234 MAIN Street suite 300 somecity, ua 12345-1234 Is this address correct for the location in Utana? [ ] YES--> Continue with Item 5 [ ] NO --> Please make changes to the right of the address here, in Item 4. Continue with Item 5
5 3	Is the following information correct for the address in Item 4? UTANA COUNTY/TOWN: WATERCRESS/DANBURY  YES...Continue with Item 6  NO.....Please print corrections in this space and then continue with Item 6.
63	Does Unemployment Insurance account 1234567890 IN UTANA belong only to a private household (not a business) that employs workers such as a maid, nanny, gardener, cook, or chauffeur.  YES...SKIP to Item 11 on the back of this page (814110, Aux 5)  NO.....Continue with Item 7
7		Which one of these statements best describes the location using Unemployment Insurance account 1234567890 IN UTANA?  This is the only location of this business in the United States, Puerto Rico, or the Virgin Islands. ...SKIP to Item 9 on the back ( 5)  This business has more than one U.S. location. At this location we mainly provide goods or services to the general public (that is, to individual consumers, other businesses, organizations, or institutions)…Continue with Item 8 ( 5)  This business has more than one U.S. location. At this location we mainly support other locations of our company. For example, this is a special purpose facility such as a headquarters, warehouse, data processing center, laboratory, or repair shop.…Continue with Item 8 (8)
8 (Do not count client sites or offsite projects that will last less than a year as separate locations.)	Does the business using Unemployment Insurance account 1234567890 IN UTANA have one physical location or more than one physical location in UTANA?  One physical location  More than one physical location. …Please attach a separate sheet. For each site, (1) list physical location address, (2) show number of employees, (3) answer Item 9, and (4) note whether "serves general public" or "supports our company."
			/// Please continue with Item 9 on the back of this page.

OFFICE USE FY02 99/99/99

SIC

AUX

NAICS

CTY

TWN

UI EMPL AUX CTY TWN OWN MEEI AT

1234567890-----175---5--123-0000--5--1--9

9	INSTRUCTIONS: Describe the business using the Unemployment Insurance account number 123456789 IN UTANA. We need detailed information to assign the correct industry code to this business. In the space provided below, describe your business activities, goods, products, or services in this state, as though you were telling a prospective employee what you do. Then give us the approximate percentage of sales or revenues resulting from each item. See examples below. Percentages should total 100%. If you are a third party agent for the business named in Item 2, such as a payroll service or accountant, please review Items 7 and 9 with your client. Goods or Products: What are they, and what do you do with them? Do you design, manufacture, sell directly to consumers, distribute to wholesalers, install, repair, or do something else with them? What are these goods or products made of? EXAMPLE 1: Major appliances: Sell to public 40%; Sell to retailers 30%; Repair 30% EXAMPLE 2: Install fiber optic cable 100% Manufacturers: What are your main products? What are your most important materials? What are the main production methods? EXAMPLE: Weaving cotton broadwoven fabrics 80%; Spinning cotton threads 20% Services: Describe in detail the services you provide. To whom do you provide those services? If you offer consulting, brokerage, management, or similar services, what are your major activities? EXAMPLE 1: Hair cutting & styling 65%; Manicures 25%; Facials 10% EXAMPLE 2: Long distance trucking, less than truckload 100% EXAMPLE 3: Marketing consulting: Planning marketing strategy 60%, Sales forecasting 40% EXAMPLE 4: Cleaning private homes 100% Construction or Building Trades: Is the work mostly residential or nonresidential? Single- or multi-family? New or remodeling? EXAMPLE: Electrical contractor: Wiring new homes 51%; Electrical refurbishing of office buildings 49%
List most important activities, goods, products, or services			_________________________________________________________________________________________________ ______% _________________________________________________________________________________________________ ______% _________________________________________________________________________________________________ ______% _________________________________________________________________________________________________ ______% _________________________________________________________________________________________________ ______%
		PLEASE PRINT CLEARLY 100%
10	Does this business have a website?  YES… Please enter the business website address here. __________________________________________…Continue with Item 11  NO…..Continue with Item 11
11	Please provide a contact for us if we have questions about this report. (Please print) Name: ___________________________________ Phone: (________)_______________________ Date: _________________ Title: _________________________________________________________________ Fax: (________)_________________________ If you are a third party agent, such as an accounting firm or payroll service, check here . Please be sure to answer Item 9 above.
Please return the completed form to this address within 14 days, using the postage-paid envelope provided. For questions concerning this form, contact: UTANA DEPARTMENT OF LABOR AND INDUSTRY DIVISION OF RESEARCH AND STATISTICS – ES-202 12345 CENTER STREET, ROOM 200 SOMECITY, UA 12345-9876 Internet: http://www.utana.dol.gov PHONE: 1-123-321-4321 FAX: 123-321-4421

Thank you for your cooperation!

Purpose and Use: The purpose of this report is to update information on your products or services. The information will be used to ensure that we assign the correct industry code to this business location, and that our records contain the correct name and address. The information collected on this form by the Bureau of Labor Statistics and the State agencies cooperating in its statistical programs will be used for statistical and Unemployment Insurance program purposes, and other purposes in accordance with law.

Time of Completion: Time of completion is estimated to vary from 5 to 45 minutes with an average of 10 minutes per form. This estimate includes time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing this information. If you have any comments regarding these estimates, or any other aspect of this survey, send them to the Bureau of Labor Statistics, Division of Occupational and Administrative Statistics (NCA), Room 4840, 2 Massachusetts Avenue N.E., Washington, D.C. 20212. You are not required to respond to the collection of information unless it displays a currently valid OMB number.

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