Bls-3023-nvs

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

UTANA DEPARTMENT OF EMPLOYMENT STATISTICS

The questions on this form concern the work location(s) using Unemployment Insurance account number: 1234567890 IN UTANA
This report is authorized by law, 29 U.S.C. 2. Your voluntary cooperation is needed to make the results of this survey
complete, accurate, and timely. Purpose, use and help information are located on the back of this form.

We appreciate your response within 14 days. Thank you.

BUSINESS MAILING ADDRESS
ALGLBKFPCMANHIFK
ANODNOAOKHHLKDGK
AKMHANBOODJAAMGK
ACKAIKOCAGGKACMK

Please Print corrections to the right of the is mailing address.

## SS USNVS01-999999 T-050 ********************SNGLP
MR SAMPLE A.
SAMPLE A SAMPLE A
SAMPLE A SAMPLE
SUITE 123
PO BOX 123
ANY TOWN, US 12345-6789

Your web ID and Password
**********************
*ID: 991234567890
*
*Password: Ab12345678*
**********************

qsqrprqrspqqpqssqsrqrqrrrsppqrpqrsssrsrrqprprsprrrrpqrsssqrsqqrqs

99

REPORTING INSTRUCTIONS
If you have changes to Items 1, 2, 3 or 4,
Visit our website to file your report. https://idcfars.bls.gov/ARS

If you DO NOT have any changes to Items 1, 2, 3 and 4,
then you may respond toll free: 1-888-256-0864

If you do not wish to use the phone or internet to file your report, please use the included postage paid envelope.

PHYSICAL LOCATION ADDRESS

Please print corrections to the right of this address. Do no include P.O. Box or Out-of-state
addresses. Check the box, if applicable.

456 ANYSTREET BLVD
STE 1000
ANYWHERE, UA 12345-6789
More than one physical location. Please attach a sheet listing each site and include: (1) business name (2) physical location address (3)
number of employees (4) county and (5) main business activity. Please do not count client sites or off-site projects lasting less than a year.

COUNTY ANY COUNTY
YES...If the information directly above is correct

NO...Please provide corrections to the right

MAIN BUSINESS ACTIVITY
In-store retail sales of prescription or nonprescription drugs and medicines. Examples include,
but are not limited to, stores such as pharmacies, drug stores, apothecaries, and health and
beauty aids stores.
DOES NOT INCLUDE predominantly retailing vitamins, nutrition supplements, or body enhancing
supplements.
DOES NOT INCLUDE electronic home shopping, mail-order, or other non-store retail sales of
prescription drugs.

446110
While your business may not be engaged in all of the economic activities listed above, does the description above accurately include your main
business activity during the past 12 months? If the business has been closed, sold, or moved out of state, please answer in terms of its former activity.
YES...Go to Item 5

%

NO...Please list the main
activities and their percentage
of sales/revenues here

%
%

CONTACT INFORMATION
Name (Please Print):

Website:

YOUR STATE FIPS AND UI ACCOUNT NUMBER:
SAMPLE AGENCY NAME
SAMPLE AGENCY DEPARTMENT
123 ANY STREET
ANYWHERE, UA 12345-6789

PHONE: (202) 691-6488
PHONE: (202) 691-6488
WWW.BLS.GOV

Phone:

FIPS: 99 UI Account Number: 1234567890
FAX: (202)691-6488

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 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 2 to 30 minutes with an average of 5 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. The OMB control number for this survey is 1220-0032.
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. In addition this section provides instructions for the completion and return of this survey.
Item 2
The physical location address is the place where you conduct your business or use as a home base of operations (i.e. sales) within the
State listed on the front of this form. This address does not include a Post Office Box. If more than one physical location, then attach a
separate sheet of paper with each location's business name, physical location address, county name (or equivalent), main business
activities and number of employees at that site. For remote locations, you may include applicable information, such as: GPS
coordinates (longitude/latitude), county/township/island/parish, road/highway/county markers, city, and 911 addresses.
Item 3
Either the county, township, island, independent city or parish of your business's physical location.
Item 4
Printed description of your main business activities, goods, products, or services in this State.
Please verify the printed description of your main business activities, goods, products, or services in this State, as though you were
telling a prospective employee what you do. If you answered no, please describe the activities in the blank lines of Item 4 and provide
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 1, such as a payroll service or accountant, please review Item 4 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 broad woven 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 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%
Item 5
Contact name, telephone number, and business website address.
Item 6
Your UI account number and State FIPS. This information is provided for your reference and does not need to be updated.