Form De 1 - Registration Form For Commercial Employers - 2012

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EMPLOYMENT DEVELOPMENT DEPARTMENT

This form will be the basic record of YOUR Account.

ACCOUNT SERVICES GROUP, MIC 28

DO NOT FILE FORM UNTIL YOU HAVE PAID WAGES THAT EXCEED

P.O. BOX 826880

$100.00 IN CALENDAR QUARTER.

SACRAMENTO CA 94280-0001

Please read INSTRUCTIONS on the back before completing form.

888-745-3886 FAX 916-654-9211

PLEASE PRINT OR TYPE in BLUE OR BLACK INK ONLY.

Submit or fax form to

REGISTRATION FORM FOR COMMERCIAL EMPLOYERS

See reverse for registration information for other business types.

EDD ACCOUNT NUMBER

QUARTER

ONLINE PROCESS DATE

Dept. Use Only:

A. LIST NAMES OF:

OWNER(S), PARTNER(S) *, CORP

SOCIAL SECURITY #

CALIFORNIA

TITLE

OFFICERS, OR LLC/LLP Members/Managers/Officers

DRIVER’S LIC #

Note: If entity is a Limited Partnership, indicate General Partner with an (*). List additional partners, LLC/LLP members/officers/managers on a separate sheet.

C. DATE OWNERSHIP

B. BUSINESS NAME:

D. FEDERAL TAX ID #:

(If none, enter N/A)

BEGAN OPERATING:

YYYY

E. CORPORATION / LLC / LLP/LP NAME:

E1. SECRETARY OF STATE

(If none, enter N/A)

CORP / LLC / LLP ID #

F. PHYSICAL BUSINESS LOCATION:

CITY

STATE ZIP CODE PHONE NUMBER

(Number and Street, not P.O. Box)

(

)

G. MAILING ADDRESS:

CITY

STATE ZIP CODE PHONE NUMBER

(P.O. Box / Number and Street, only if different than F)

(

)

Note: If you have multiple CA locations, please attach the physical business addresses on a separate sheet of paper.

H. INDICATE FIRST QUARTER & YEAR WAGES EXCEEDED $100:

Jan-Mar 20

Apr-Jun 20

Jul-Sept 20

Oct-Dec 20

I. HAVE YOU EVER OWNED OR BEEN A PRINCIPAL

J. FORMER EDD ACCOUNT NUMBER(S):

OWNER IN A BUSINESS REGISTERED WITH THE EDD:

BUSINESS NAME:

ADDRESS:

Yes

If Yes, complete J.

NOTE: If necessary, please provide additional information on a separate sheet.

K. THIS IS A:

New Business

Hired Employees

Purchased a Business **

Other (Specify)

All

Part

If business was purchased, mark appropriate box and complete the information below:

1. Previous Owner

2. Previous Business Name

3. Previous EDD Account #

4. Purchase Price

5. Date of Transfer

Note: For all other changes in form/ownership to your account, please use the Change of Employer Account Information (DE 24).

L. ENTER THE NUMBER OF EMPLOYEES:

M. EMPLOYEE IS:

Spouse

Minor Child

Employer’s Parent

(Under 18)

Number of employees working in CA

If Yes to any of the above, please refer to instructions on reverse.

Number of employees residing in CA and working out of CA

N. TAXPAYER TYPE:

Individual Owner

Limited Partnership

Estate Administration

Other (Specify)

Co-Ownership

Association

Trusteeship

General Partnership

Limited Liability Company

Joint Venture

Corporation

Limited Liability Partnership

Receivership

P. INDUSTRY ACTIVITY: Check the industry, product, or service that represents the greatest portion of

O. EMPLOYER TYPE:

your sales or revenue:

COMMERCIAL

Services

Retail

Wholesale

Manufacturing

Professional Employer Organization

PACIFIC MARITIME

Temp Services

Leasing Employer

Other (Specify)

FISHING BOAT

Also, describe specific product and/or service in detail:

Q. CONTACT PERSON FOR BUSINESS:

TITLE/COMPANY NAME

DAYTIME PHONE NUMBER:

(

)

ADDRESS:

FAX NUMBER: (

)

E-MAIL ADDRESS:

BUSINESS WEBSITE:

R. DECLARATION

I certify under penalty of perjury that the above information is true, correct and complete, and that these actions are not being taken to receive a more

favorable Unemployment Insurance Rate. I further certify that I have the authority to sign on behalf of the above business.

Signature: _________________________________________________________ Title:

(Owner, Corporate Officer, Partner, LLC/LLP Member/Manager, or authorized Agent)

Printed Name:

Phone Number: (

)

Date:

DE 1 Rev. 76 (11-12) (INTERNET)

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