Ui-1 R 12/06 - Status Registration - Mississippi Department Of Employment Security Page 3

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UI-1
STATUS REGISTRATION
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I hereby certify that all the information contained above is true and correct to the best of my knowledge.
Date
:
Firm Name:
(MM/ DD /CCYY)
Signature:
Title:
Mississippi Department of Employment Security is an equal opportunity employer.
UI-1 R-12/2006
Web Address:
Auxiliary aids and services are available upon request to individuals with disabilities.
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