Bls-3023-nvm

Industry Verification Form, BLS 3023−NVM
Form Approved, O.M.B. No. 1220−0032
In cooperation with the U.S. Department of Labor

Page 1

Utana Department of Labor and Industry

We appreciate your response within 14 days. Please return all pages in the enclosed postage-paid envelope. Thank you.

1

BUSINESS MAILING ADDRESS Please print corrections to the right of this mailing address.

2

MAIN BUSINESS ACTIVITY OF EACH WORKSITE
In Section A, you will find a list of the worksites of your business. Please review the list for accuracy and provide
corrections, if applicable, in the space provided on that sheet. Further instructions are printed in Section A.

3

ADDITIONAL WORKSITES
If the list of worksites in Section A does not include all of the worksites for the Unemployment Insurance
account number printed above, please enter information for the missing worksites in Section B. Further
instructions are printed in Section B.

4

CONTACT INFORMATION
Name (Please Print)

Title

Date

Phone

(

)

-

Email Address
Business Website Address

For questions
concerning this
form, contact:

EM-283886-1:654321

OFFICE USE

Page 2

Purpose and Use: The purpose of this report is to update information on your products or services for your business worksites. The
information will be used to ensure that we assign the correct North American Industry Classification System (NAICS) 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 15 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 Administrative Statistics and Labor Turnover, 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.
Information Immediately Above Item 1 of Form
This block shows the ten-position Unemployment Insurance (UI) account number assigned to this business, the State or U.S. territory that
assigned it (and to which the business reports for UI purposes), and the applicable State and/or federal laws pertaining to completion of
this form.
Item 1
The address that receives your business mail.
Item 2
In Section A, you will find the listing of your worksites with their Main Business Activities. A detailed description of the business activity
can be found on page 3. If the information is correct, please check the box labeled “Yes.” If the information is incorrect, please check the
box labeled “No,” and in the space provided, describe your business activities, goods, products, or services as though you were telling a
prospective employee what you do. Provide the approximate percentage of sales or revenues resulting from each activity. See examples
below. Percentages should total 100%. If you are a third-party agent for the business named in Item 1, such as a payroll service or
accountant, please review this information with your client.
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 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%
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 broad woven fabrics 80%; Spinning cotton threads 20%
Item 3
In Section B, please provide additional worksites not included in Section A. Please include: (1) trade name (2) physical location address
(3) worksite description (4) number of employees (5) date opened and (6) main business activity.
(1) Trade Name: The trade name for this worksite.
(2) Physical Location Address: The physical location address is the place where you conduct your business or use as a home base of
operations (e.g. sales) within the State listed on the front of this form. This address does not include a Post Office Box.
(3) Worksite Description: A brief description of the worksite, for example “Store number 123.”
(4) Number of Employees: The number of employees currently working at this location.
(5) Date Opened: The date the worksite opened or was acquired by your business.
(6) Main Business Activity: Please describe the activities and provide the approximate percentage of sales or revenues resulting from
each activity. See examples in the Item 2 instructions above. Percentages should total 100%.
Item 4
Contact name, date, title, telephone number, email address, and business website address.

Industry Verification Form, BLS 3023−NVM
Form Approved, O.M.B. No. 1220−0032

UI:

Main Business Activity Descriptions

State:
The goal is to verify the Main Business Activity for each worksite. These descriptions may not include all activities
at a worksite and/or there may be some activities listed that do not apply. If the industry description is applicable,
then you may consider it to be the correct industry for that worksite. If not, please provide a more accurate
description in the space provided in Section A.

Page 3

UI:

State:

Main Business
Activity Descriptions
(continued)

Page 4

283886-2/3

Industry Verification Form, BLS 3023−NVM
Form Approved, O.M.B. No. 1220−0032

SECTION A
MAIN BUSINESS ACTIVITY

Page 5

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

MAIN BUSINESS ACTIVITY

Please print clearly
If you have any worksites not listed in Section A, please provide them in Section B

NUMBER OF
EMPLOYEES

%
%
%

%
%
%

%
%
%

%
%
%

%
%
%

%
%
%

OFFICE USE

Instructions:
Please review the Main Business Activity printed for each worksite. Please refer to page 3 for descriptions of the business activity.
• If the information for that worksite is CORRECT, check the “Yes” box.
• If the information for that worksite is INCORRECT, check the “No” box and describe your business activities, goods, products, or
services in the space provided below. Note the approximate percentage of sales/revenue for each item. Percentages should total 100%.
• If the worksite is closed or sold, then please draw a line through the worksite. Write “Closed” or “Sold” and the date this took place. For “Sold” worksites,
if known, please provide the name and Unemployment Insurance account number of the company that made the purchase.

State:

TRADE NAME, STREET ADDRESS (physical location)
CITY, STATE, AND ZIP CODE, WORKSITE DESCRIPTION (plant name, store number, etc)

UI:

Industry Verification Form, BLS 3023−NVM
Form Approved, O.M.B. No. 1220−0032

State:

283886-3/3

NUMBER OF
EMPLOYEES

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

SECTION A
MAIN BUSINESS ACTIVITY
(continued)
MAIN BUSINESS ACTIVITY

Please print clearly
If you have any worksites not listed in Section A, please provide them in Section B

TRADE NAME, STREET ADDRESS (physical location)
CITY, STATE, AND ZIP CODE, WORKSITE DESCRIPTION (plant name, store number, etc)

UI:

Industry Verification Form, BLS 3023−NVM
Form Approved, O.M.B. No. 1220−0032

%
%
%

%
%
%

%
%
%

%
%
%

%
%
%

%
%
%

%
%
%

OFFICE USE

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State:

NUMBER OF
EMPLOYEES

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

SECTION A
MAIN BUSINESS ACTIVITY
(continued)
MAIN BUSINESS ACTIVITY

Please print clearly
If you have any worksites not listed in Section A, please provide them in Section B

TRADE NAME, STREET ADDRESS (physical location)
CITY, STATE, AND ZIP CODE, WORKSITE DESCRIPTION (plant name, store number, etc)

UI:

Industry Verification Form, BLS 3023−NVM
Form Approved, O.M.B. No. 1220−0032

%
%
%

%
%
%

%
%
%

%
%
%

%
%
%

%
%
%

%
%
%

OFFICE USE

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State:

NUMBER OF
EMPLOYEES

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

SECTION A
MAIN BUSINESS ACTIVITY
(continued)
MAIN BUSINESS ACTIVITY

Please print clearly
If you have any worksites not listed in Section A, please provide them in Section B

TRADE NAME, STREET ADDRESS (physical location)
CITY, STATE, AND ZIP CODE, WORKSITE DESCRIPTION (plant name, store number, etc)

UI:

Industry Verification Form, BLS 3023−NVM
Form Approved, O.M.B. No. 1220−0032

%
%
%

%
%
%

%
%
%

%
%
%

%
%
%

%
%
%

%
%
%

OFFICE USE

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State:

NUMBER OF
EMPLOYEES

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

SECTION A
MAIN BUSINESS ACTIVITY
(continued)
MAIN BUSINESS ACTIVITY

Please print clearly
If you have any worksites not listed in Section A, please provide them in Section B

TRADE NAME, STREET ADDRESS (physical location)
CITY, STATE, AND ZIP CODE, WORKSITE DESCRIPTION (plant name, store number, etc)

UI:

Industry Verification Form, BLS 3023−NVM
Form Approved, O.M.B. No. 1220−0032

%
%
%

%
%
%

%
%
%

%
%
%

%
%
%

%
%
%

%
%
%

OFFICE USE

Page 9

State:

NUMBER OF
EMPLOYEES

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

SECTION A
MAIN BUSINESS ACTIVITY
(continued)
MAIN BUSINESS ACTIVITY

Please print clearly
If you have any worksites not listed in Section A, please provide them in Section B

TRADE NAME, STREET ADDRESS (physical location)
CITY, STATE, AND ZIP CODE, WORKSITE DESCRIPTION (plant name, store number, etc)

UI:

Industry Verification Form, BLS 3023−NVM
Form Approved, O.M.B. No. 1220−0032

%
%
%

%
%
%

%
%
%

%
%
%

%
%
%

%
%
%

%
%
%

OFFICE USE

Page 10

SECTION B
ADDITIONAL WORKSITES

Page 11

For questions
concerning this
form, contact:

Trade Name:
Street:
City:
State:
Worksite Description:

Trade Name:
Street:
City:
State:
Worksite Description:

Trade Name:
Street:
City:
State:
Worksite Description:

Trade Name:
Street:
City:
State:
Worksite Description:

Zip + 4:

Zip + 4:

Zip + 4:

Zip + 4:

Zip + 4:

BUSINESS WORKSITE INFORMATION

NUMBER OF
EMPLOYEES

Please print clearly

(i.e.,01/01/09)

DATE
OPENED

MAIN BUSINESS ACTIVITY

%
%
%
%

%
%
%
%

%
%
%
%

%
%
%
%

%
%
%
%

OFFICE USE

Instructions:
If there are additional worksites for your business in XXXXXXXXXXXXX that are not listed in Section A, please provide the trade name, physical location
address, worksite description, number of employees and date opened. Also provide a brief list of business activities, goods, products, or services and note
the approximate percentage of sales/revenue from each item. Percentages should total 100%. If the additional worksite was purchased from another
company, then please provide the name and Unemployment Insurance account number, if known, from which the worksite was purchased. If needed, please
make copies or attach extra pages for additional worksites.

State:

Trade Name:
Street:
City:
State:
Worksite Description:

UI:

Industry Verification Form, BLS 3023−NVM
Form Approved, O.M.B. No. 1220−0032

For questions
concerning this
form, contact:

Trade Name:
Street:
City:
State:
Worksite Description:

Trade Name:
Street:
City:
State:
Worksite Description:

Trade Name:
Street:
City:
State:
Worksite Description:

Trade Name:
Street:
City:
State:
Worksite Description:

Trade Name:
Street:
City:
State:
Worksite Description:

Zip + 4:

Zip + 4:

Zip + 4:

Zip + 4:

Zip + 4:

Zip + 4:

BUSINESS WORKSITE INFORMATION

State:

Trade Name:
Street:
City:
State:
Worksite Description:

UI:

Industry Verification Form, BLS 3023−NVM
Form Approved, O.M.B. No. 1220−0032

NUMBER OF
EMPLOYEES

Please print clearly

(i.e.,01/01/09)

DATE
OPENED

SECTION B
ADDITIONAL WORKSITES
(continued)
MAIN BUSINESS ACTIVITY

%
%
%
%

%
%
%
%

%
%
%
%

%
%
%
%

%
%
%
%

%
%
%
%

OFFICE USE

Page 12