Form BLS-3023-NVS / BLS BLS-3023-NVS / BLS BLS-3023-NVS / BLS-3023-NCA (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-NVS
Form Approved, O.M.B. No. 1220-0032
Expiration Date: 12/31/2017
In cooperation w ith 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: __________

PHYSICAL LOCATION ADDRESS of your business location in California. Please print.
Street Address: _____________________________________________ ___________________________

City: __________________________________________________ ST: California ZIP: ________________
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 w orking in California but no physical location in California. If so, please continue to Item 4.

COUNTY: ________________________________________________
Please provide the County where your business is physically located in California.

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 thirdparty 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
percentages of
sales/revenue
here:

______________________________________________________________

__________ %

______________________________________________________________

__________ %

______________________________________________________________

__________ %

______________________________________________________________

__________ %

______________________________________________________________

__________ %

CONTACT INFORMATION
Name: ___________________________________ Email: _____________________________________ Phone: ____________________

INSTRUCTIONS
You may return this form via FAX: (916) 651-5771 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. 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 is estimated to vary from 2 to 30 minutes with an average of 5 minutes per
form. Time of completion for the NCA is estimated to vary from 5 to 45 minutes with an average of 10 minutes per form. These
estimates include 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. The OMB control number for this survey is 1220-0032.
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
The physical location address is the place where you conduct your business or use as a home base of operations (i.e. sales) w ithin
the State listed on the front of this form. This address does not include a Post Office Box. If more than one physical locati on, 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, or 911 addresses.
Item 3
Either the county, township, island, independent city or parish of your business's physical location.
Item 4
If there is a main business description for your business on file, it will be printed in Item 4. Please verify the printed descr iption 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, please describe your main business activities,
goods, products, or services in this State, as though you were telling a prospective employee what you do. Pleas e 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 consum ers,
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 y ou 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 truck ing, less than truck load 100%
EXAMPLE 3: Mark eting 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 refurb ishing of office buildings 49%
Item 5
Contact name, email, and telephone number.