Maryland New Hire Registry Reporting Form
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1Maryland New Hire Registry Reporting Form
To ensure the highest level of accuracy, please print neatly in
Send completed forms to:
capital letters and avoid contact with the edges of the boxes.
Maryland State Directory of New Hires
The following will serve as an example:
PO Box 1316
Baltimore, MD 21203-1316
ABC
123
Fax: (410) 281-6004 or toll-free fax 1 (888) 657-3534
EMPLOYER INFORMATION
Federal Employer Id Number (FEIN):
State Unemployment Insurance Number (MD Only SUIN):
Please use the same FEIN that appears on quarterly wage reports.
If SUIN not issued yet, please write “APPLIED FOR” in
the above box. If Exempt, write “EXEMPT”.
Employer Name:
Employer Address (Please indicate the address where the Income Withholding Orders should be sent):
Employer City:
Employer State:
Zip Code (5 digit):
Employer Phone (optional):
Employer Fax (optional):
Contact Name (optional):
Email (optional):
EMPLOYEE INFORMATION
Employee Social Security Number (SSN):
Date of Hire (mm/dd/yyyy):
Middle Initial
Employee First Name:
(optional):
Employee Last Name:
Employee Address:
Employee City:
Employee State:
Zip Code (5 digit):
Date of Birth mm/dd/yyyy (optional):
Employee Salary (Dollars and Cents):
Hourly
Monthly
Yearly
Are health care benefits available to employee? (Y/N):
Employee Gender (M)ale/(F)emale:
Rev. (09/02)
Reports must be submitted within 20 days of the date of hire or rehire
Questions? Call us at (410) 281-6000 or toll-free 1 (888) MDHIRES (634-4737). Report online at
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Parent category: Business