EVS Registration Form

EVS Registration Form
Complete this form, along with the appropriate privacy act statement and mail or
fax to:
Social Security Administration
OCO, DES, EVS
5-E-10 North Building
300 N. Greene Street
Baltimore, Maryland 21290-0300
Fax (410) 966-3366 or (410) 966-9439

1. Name of Company

2. Company Street Address, City, State, Zip Code (P.O. Box alone is not
acceptable)

3. EIN (Employer Identification Number)
Provide primary EIN if your company uses more than one.
4. Contact Name and Telephone Number (include area code)

5. Fax number (if applicable)
6. How many SSNs do you want to verify? _____
7. Are you a Third-Party submitter?

Yes ___

No ___

8. Authorized Signature (Company Manager or Authorized Representative)

______________________________________
Signature
______________________________________
Title

___________________
Date