Form Sfn 41216 - Report To Determine Liability Page 3
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4SFN 41216 (1-2013)
Page 3 of 4
21. Business Locations: Enter the North Dakota addresses from which your employees work and indicate if the location is permanent or
temporary. If you do not maintain an office in North Dakota, enter the employee's address.
Address
City
State
ZIP Code
Telephone
Permanent Temporary
Remarks:
22.
Name of Authorized Representative
Title
Telephone Number
Fax Number
Name of Individual Completing Form
Title
Telephone Number
Date
I certify the information on SFN 41216, Report to Determine Liability, is true and accurate.
Go
Submit
Job Service is an equal opportunity employer/program provider.
Auxiliary aids and services are available upon request to individuals with disabilities.
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Parent category: Business