BLS-3023-NVS (Non-CARS, Non-TRS Eligible)

Industry Verification Form, BLS 3023−NVS
UTANA DEPARTMENT OF LABOR AND INDUSTRY
Form Approved, O.M.B. No. 1220−0032
In cooperation with the U.S. Department of Labor
The questions on this form concern the work location(s) using Unemployment Insurance account number: 1234567890 IN UTANA.
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. Purpose, use and help information are located on the back of this form.

A

Please place your completed form in the enclosed postage paid envelope and return it within 14 days of receiving it. Thank you.

1 BUSINESS MAILING ADDRESS

Please print corrections to right of printed mailing address:

ATTN: MARY CAPPS
XYZ ADVISORS
4TH FLOOR
1310 SILVER STREET
SOMECITY UA 12345−6789

2 PHYSICAL LOCATION ADDRESS of your business.

Please mark all boxes that apply.
Same as Business Mailing Address
Different Physical Location Address than Business Mailing Address. Please enter below. Do not use P.O. Box.
STREET ADDRESS: ___________________________________________________________________________
CITY: _________________________________________________

STATE: _____

ZIP+4: _________ − ______

Business has employees but no physical location in UTANA
Check if more than one physical location. Please attach a separate sheet for each site: List: (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 offsite
projects that will last less than a year.

3 COUNTY/TOWN: WATERCRESS/ROCKYSTEP
YES...If the information directly above is correct
NO....Please correct to the right

4 MAIN BUSINESS ACTIVITY
Furnishing customized investment advice to clients on a fee basis but do not have the authority to
execute trades. Primary activities performed by establishments in this industry are providing
financial planning advice and investment counseling to meet the goals and needs of specific
clients. EXAMPLES: futures advisory services, investment advisory services, and investment
research.

523930

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 this State, please answer in
terms of its former activity.)
Must equal
100%
YES...GO to Item 5
%
NO...Please list the main activities and
their percentage of sales/revenues
%
here
%

5 CONTACT INFORMATION

Name
(Please Print): ___________________________________________

Phone: (_____) __________ Business Website Address: ____________________________________

For questions
concerning this
form, contact:

UTANA DEPARTMENT OF LABOR AND INDUSTRY
DIVISION OF RESEARCH AND STATISTICS − QCEW
12345 CENTER STREET, ROOM 200
SOMECITY, UA 12345−9876
INTERNET: http://www.utana.dol.gov
PHONE: 1−123−321−4321
FAX: 123−321−4421

OFFICE USE FY14 11/12/13
CMI
EMPL
NAICS
CTY TWN4 OWN MEEI AT
00−−−−−−125−−523930−−−101−−−333−−−5−−−−1−−−−1
NAICS

CTY

TOWN

///

RC

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 (NVS), 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.
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. Please make corrections, if necessary.
Item 4
Preprinted description of your main business activities, goods, products, or services in this State.
Please verify the preprinted 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.