Bls-3023-nca (cars)

S AMPLE AGENCY NAME Industry Verification Form, BLS 3023-NCA

SAMPLE AGENCY DEPARTMENT Form Approved, O.M.B. No. 1220-0032

123 ANY STREET In cooperation with the U.S. Department of Labor

A NYWHERE, UA 12345-6789

The questions on this form concern the work location(s) using Unemployment Insurance account number: 1234567890 IN UTANA

This report is mandatory under Utana Law 18-12-100, and is authorized by 2 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.

1

We appreciate your response within 14 days. Thank you.

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

ATTN: MARY CAPPS Your Web ID and Password

XYZ ADVISORS *************************

4TH FLOOR * ID: 991234567890 *

1310 SILVER STREET * Password: Ab123456 *

SOMECITY UA 12345−6789 *************************

99

REPORTING INSTRUCTIONS

GO PAPERLESS!! Report your data on the web. If you do not wish to use the website,

Visit our secure website to file your report. Please return this form in the enclosed

https://idcfars.bls.gov/ postage paid envelop.

2

PHYSICAL LOCATION ADDRESS of your business in UTANA. Please check all boxes that apply.

Street Address

City UTANA STATE Zip+4 -

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 & (5) main business activity. Please don't count client sites or off-site projects lasting less than a year.

Business has employees working in UTATA STATE but no physical location in WASHINGTON STATE. If so, please continue to item

3

COUNTY:

Please provide the COUNTY where your business in physically located.

4

MAIN BUSINESS ACTIVITY

We need detailed information to assign the correct North American Industry Classification System (NAICS) 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. Please describe the activities and provide the approximate percentage of sales or revenues

resulting from each activity. For more information see instructions and examples for Item 4 on the back of this page. 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.

%

%

%

%

Must equal 100%

Please list the

main activities

and their

percentage of

sales/revenues

%

here

5

CONTACT INFORMATION Please print.

Name: Email: Phone:

6

UI ACCOUNT State Code: 99 UI Account Number: 123456789

STATE AGENCY NAME

For questions PHONE: (123) 456-7890 FAX: (123) 456-7890 OFFICE USE FY15 10/15/14

concerning this PHONE: (123) 456-7890 CMI EMPL NAICS CTY TWN4 OWN MEEI AT

form, contact: WWW.WEBSITE.COM 00 1000 123456 123 --- 5 1 U

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 for the NVS form is estimated to vary from 2 to 30 minutes with an average of 5 minutes per form. Time of completion for the NCA form is estimated to vary from 5 to 45 minutes with an average of 10 minutes per form. These estimates 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 4940, 2 Massachusetts Avenue N.E., Washington, D.C. 20212. You are not required to respond to the col lection 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 along with 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 you have more than one physical location, 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

If we have a main business activity for your business on file, it will be printed in Item 4. Please verify the printed description of your main business activities, goods, products, or services in this State.

If there is no main business activity printed, or the printed activity does not accurately reflect the main business activity of your company, describe your business activities, goods, product or services as though you were telling a prospective employee what you do. Please 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

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 this them? What are these goods and products made of?

EXAMPLE 1: Major appliances: Sell to public 40%; Sell to retailers 30%; Repair 30%

EXAMPLE 2: Install fiber optic cables 100%

Manufacturers: What are your main products? What are your most important materials? What are the main production methods?

EXAMPLE: Weaving cotton brood 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: Haircutting & 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: Cleating private homes 100%

Construction or Building Trades: Is the work mostly residential or nonresidential? Single or multi family homes? 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 State code and UI account number. This information is provided for your reference and does not need to be updated.