BLS-3023-NVM (Cali BLS-3023-NVM (California Example)

California Employment Development Dept
Labor Market Information Division
P.O. Box 826220
Sacramento, CA 94299-9977
Phone: 1-800-562-3366
FAX: (916) 651-5771 or (916) 651-5770
Unemployment Insurance Account Number:

Industry Verification Form, BLS 3023-NVM
Form Approved, O.M.B. No. 1220-0032
Expiration Date: 12/31/2017
In cooperation with the U.S. Department of Labor

________________________________________ in California.

This report is mandatory under Section 320.5 of the California Unemployment Insurance Code and Section 320-1
Title 22 of the California 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.
We appreciate your response within 14 days. Thank you.

BUSINESS MAILING ADDRESS Please print.
Business Name: _______________________________________________________________________________

Street Address: ________________________________________________________________________________

City: __________________________________________________ ST: ___________________ ZIP: __________

MAIN BUSINESS ACTIVITY OF EACH LOCATION ADDRESS

In Section A, please provide a list of all worksites of your business within the state. Please make sure to
provide the physical location address for each worksite, along with a brief description of the main business
activity at each location. Further instructions are printed in Section A.

CONTACT INFORMATION
Name: _______________________________________________________

Date: ____________________

Title: ________________________________________________________

Phone: ___________________

Email: _____________________________________________________________________________________
Website: ___________________________________________________________________________________

You may return this form via FAX: (916) 651-5771 or (916) 651-5770 or by mail:
California Employment Development Dept
Labor Market Information Division
P.O. Box 826220
Sacramento, CA 94299-9977

INSTRUCTIONS
You may return this form via FAX: (916) 651-5771 or (916) 651-5770 or by mail:
California Employment Development Dept
Labor Market Information Division
P.O. Box 826220
Sacramento, CA 94299-9977
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 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 10 to 60 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 1830, 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 Above Item 1
The ten-digit 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
Refers to Section A, where you are asked to provide information for your business worksite locations.
Item 3
Contact name, date, title, telephone number, email address, and business website.
Information Above Section A
The Unemployment Insurance (UI) account number assigned to this business. (This is the same UI account number from the first
page of this form.)
Section A
In Section A, you are asked to provide a list of your worksite locations in California and to describe your main business activities. In
the space provided, list 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%
For Section A, please use as many sheets as you need to list all of your business worksites in California.

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