Application And Agreement For Partial Transfer Of Experience Rating Record Form - Louisiana Workforce Commission Page 2

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FAX: (225) 346-6074
Louisiana Workforce Commission
Post Office Box 94186
Baton Rouge, LA 70804-9186
PARTIAL TRANSFER OF EXPERIENCE RATING RECORD
(Supplement to Application & Agreement)
Enter in item 3 below the names and social security numbers of all employees on the payroll of the
transferred portion of the business as of the date of transfer shown in item 3 on page one.
KEEP A COPY FOR YOUR RECORDS
1. Successor Employer Name: __________________________________ Account No. _____________
2. Predecessor Employer Name: _________________________________ Account No. ____________
3. List of employees of transferred portion:
Social Security Number
Name
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PART TRANS SUPP web (REV 6/09)
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