Form C-1 - Employer Status Report Page 2
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28. VERMONT PHYSICAL LOCATION WHERE SERVICES ARE PERFORMED - STREET (NOT RFD OR P.O. BOX #)
TELEPHONE NUMBER
CITY
STATE
ZIP CODE
FAX NUMBER
9. DO YOU HAVE WORKERS PERFORMING SERVICES FOR YOUR BUSINESS WHOM YOU CONSIDER TO BE SELF-EMPLOYED OR INDEPENDENT CONTRACTORS?
YES
NO
IF YES, PLEASE ATTACH A LIST PROVIDING NAME, ADDRESS, TELEPHONE AND TYPE OF SERVICE PROVIDED/PERFORMED.
10. DID YOU ACQUIRE THE ORGANIZATION, TRADE, BUSINESS OR ANY ASSETS OF ANY OTHER VERMONT EMPLOYER?
YES - Complete items 11A-11F and 12
NO, GO TO ITEM 12
DID YOU INCORPORATE YOUR VERMONT PROPRIETORSHIP OR PARTNERSHIP?
YES - Account No.: __________________________
If YES, Complete items 11A-11F
NO - Go to item 12
11A. DID YOU ACQUIRE
ALL?
PART?
11B. DATE ACQUIRED __________________
11C. UNEMPLOYMENT ACCOUNT NUMBER OF BUSINESS ACQUIRED _________________
11D. NAME OF BUSINESS ACQUIRED _________________________________________________________________________________________________________________
11E. NUMBER OF EMPLOYEES RETAINED FROM FORMER OWNER
NONE
SOME
ALL
HOW MANY? ___________________________
11F. HOW WAS BUSINESS ACQUIRED? (check one)
PURCHASE
MERGER
FRANCHISE
ENTITY CHANGE
LEASE (SPECIFY NATURE OF THE LEASE) ____________________________________________________________________________________________
12. HAVE YOU EVER HAD A VERMONT UNEMPLOYMENT ACCOUNT NUMBER FOR THIS BUSINESS OR ANY OTHER LEGAL BUSINESS ENTITY?
YES
NO IF YES, GIVE FULL BUSINESS NAME ________________________________________________________________________________________________
NATURE OF BUSINESS ACTIVITY
13A. PROVIDE A DETAILED DESCRIPTION OF THE NATURE OF ACTIVITY
13B. LIST PRINCIPLE PRODUCT(S) OR SERVICE(S), IN ORDER OF
IN VERMONT.
IMPORTANCE.
13C. PLEASE SELECT THE APPROPRIATE CATEGORY BELOW WHICH CLOSELY DESCRIBES YOUR BUSINESS IN VERMONT. IF YOU HAVE
MULTIPLE BUSINESS TYPES, PLEASE SPECIFY THE PERCENTAGES IN 13A. ABOVE. PLEASE BE SURE TO PROVIDE DETAILS IN 13A AND 13B.
Agriculture, Forestry, Fishing & Hunting
Transportation & Warehousing
Educational Services
Mining
Information
Health Care & Social Assistance
Utilities
Finance & Insurance
Arts, Entertainment & Recreation
Construction
Real Estate & Rental & Leasing
Accommodation & Food Services
Manufacturing
Professional, Scientific & Technical Services
Other Services (Except Administrative)
Wholesale Trade
Management of Companies & Enterprises
Public Administration
Retail Trade
Administrative & Waste Services
IF YOU ARE UNSURE OF THE CATEGORY IN WHICH YOUR BUSINESS FALLS, CONTACT LABOR MARKET INFORMATION AT (802) 828-3868 OR ACCESS THE WEB AT
FOR MORE INFORMATION.
14. ENTER THE NUMBER OF ESTABLISHMENTS THE ABOVE BUSINESS OPERATES IN VERMONT
If more than ONE location, attach a list specifying each
INCLUDE: Home(s) of personnel, when the company does not have an office or worksite in Vermont.
location with the STREET ADDRESS, CITY AND THE
NUMBER OF WORKERS AT EACH LOCATION.
EXCLUDE: Locations that are temporary (exist less than 1 year) or are not staffed on a regular basis.
15. The following information is necessary as future notices will be available electronically. If the general contact is also responsible for UI Tax and Benefit
information, enter "Same" in those areas.
UI General Contact*
UI Tax Contact
UI Benefit Contact
INTERNAL contact if other contacts fail:
Person/Service that completes UI Tax Returns
Person/Service that completes separations/wage
requests
E-MAIL*:______________________________
E-MAIL:______________________________
E-MAIL:______________________________
* REQUIRED
16. SIGNATURE OF OWNER, PARTNER, OFFICER OF CORP., OR HEAD OF HOUSEHOLD
TITLE
DATE
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Parent category: Legal