Alaska Employer Registration Form For Daycare Services Page 3

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Alaska Employer Registration Form for Daycare Services
Account Number
Bus. Type
NAICS
Predecessor
Predecessor
Dues?
New
Alaska Department of Labor
Update
and Workforce Development
Employment Security Tax
Field Auditor
Cont.
Rt-Hld
Rate
Rate
Rate
Rate
Receive
&
Code
Mailings
Code
Year
Link
Date
PO Box 115509, Juneau, AK 99811-5509
Type
THE ABOVE AREA IS FOR STATE USE ONLY
1) Type of Employer:
Sole Proprietor
Other (Please explain)
2) Federal Identification Number (if available):
3) Were you ever assigned an account number by this
Agency?
Yes
No
If yes, list number:
4) Date first paid wages:
5a) Do you anticipate paying wages totaling $1,000 or more in a
calendar quarter this year?
Yes
No
Month _______ Day ____ Year ________
5b) Did you pay wages totaling $1,000 or more in a calendar
(Your account will be opened this date)
quarter last year?
Yes
No
Qtr 1 = Jan/Feb/March
Qtr 3 = July/Aug/Sep
Qtr 2 = April/May/June
Qtr 4 = Oct/Nov/Dec
6) Mailing Address:
City
State
Zip
7) Work Phone:
8) Physical Worksite Address in Alaska:
9) Fax Number:
10)
Are you enrolled in a daycare assistance program?
Yes
No
If yes, please provide ____________________________________________________________ (_____)_______________
Program Name
Telephone Number
11) Select all that apply:
a)
Daycare provided in my home.
Daycare provided in caregiver’s home.
b)
c)
Daycare provided by a relative.
Relative’s relationship to you: _________________________________________________ Relative’s Age ________
d) Caregiver’s Name: _______________________________________________ SSN: ___________________
CERTIFICATION: With my signature, I certify that information provided on this form is correct and true to the best of my belief.
Residence Address &
Responsibility
Printed Name & Social Security Number
Signature
Title
Telephone Number
Code
City: ____________
Name:_________________________
State: ____________
Zip Code: _________
SSN: __________________________
Home phone:
City: _____________
Name: _________________________
State: ____________
Zip Code: _________
SSN: __________________________
Home phone:
Business Contact Person:
Phone Number:
E-mail:
Page 3
Form TREG (daycare) (11/07)

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