Form De 1np - Nonprofit Employers Registration And Update Form - 2016 Page 2

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NONPROFIT EMPLOYERS
REGISTRATION AND UPDATE FORM
01NP11152
I.
DOING BUSINESS AS (DBA) (If applicable)
J.
FEDERAL EMPLOYER IDENTIFICATION NUMBER (FEIN)
K. DATE OWNERSHIP BEGAN (MM/DD/YYYY)
____/____/______
L.
STATE OR PROVINCE OF INCORPORATION/ORGANIZATION
M. CALIFORNIA SECRETARY OF STATE ENTITY NUMBER
N. PHYSICAL BUSINESS
Street Number
Street Name
Unit Number (If applicable)
LOCATION
(PO Box or Private
City
State/Province
Country
ZIP Code
Mail Box will not be
accepted.)
Business Phone Number
Street Number
Street Name
Unit Number (If applicable)
O. MAILING ADDRESS
(PO Box or Private Mail
Box is acceptable.)
City
State/Province
Country
ZIP Code
Same as above
Phone Number
Valid E-mail Address
P.
E-MAIL
Check to allow
e-mail contact.
Q. INDUSTRY ACTIVITY
Describe in detail your specific product/services:
R. CONTACT PERSON
Name
Contact Phone Number
E-mail Address
(Complete a Power of
Attorney [POA] Declaration
Relation
Address
[DE
48], if applicable.)
S. 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
Date
Name
Title
Phone Number
PRINT
DE 1NP Rev. 8 (2-16) (INTERNET)
Page 2 of 4

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