Form Eta 9059 - Questionnaire On Commerce Information - National Labor Relations Board
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1INTERNET
FORM EXEMPT
NATIONAL LABOR RELATIONS BOARD
FORM NLRB-5081
UNDER 44
QUESTIONNAIRE ON COMMERCE INFORMATION
(2-08)
U.S.C. 3512
Please read carefully. Answer all applicable items and return to the Regional Office. If additional space is required, use plain bond paper and identify item number.
CASE NAME
CASE NUMBER
1. TYPE OF BUSINESS
[
]
[ ]
[ ]
CORPORATION
PARTNERSHIP
SOLE PROPRIETORSHIP
2. CLASSIFICATION WHICH DESCRIBES YOUR BUSINESS
[ ]
[
]
[
]
[
]
WHOLESALING
NEWSPAPER
OFFICE OF INDUSTRIAL BUILDING
RETAIL
[
]
[
]
[
]
[
]
HOSPITAL
HOTEL - MOTEL
MANUFACTURING/PROCESSING
SERVICE ORGANIZATION
]
[
]
[
]
[
]
[
TRUCKING
PUBLIC UTILITY
BROADCASTING STATION
NURSING HOME
[ ]
[
]
[
]
TRANSIT SYSTEM
BUILDING AND CONSTUCTION
OTHER (Describe)
3. EXACT LEGAL TITLE OF FIRM
4. IF A CORPORATION
A.
INCORPORATED IN
B. NAME(s) AND ADDRESS(es) OF PARENT, SUBSIDIARY, OR RELATED CORPORATION, IF ANY, AND DESCRIBE RELATIONSHIP.
STATE OF:
5. IF A PARTNERSHIP
FULL NAME AND COMPLETE ADDRESS OF ALL PARTNERS.
6. IF A PROPRIETORSHIP
FULL NAME AND COMPLETE ADDRESS OF PROPRIETOR.
7. BRIEFLY DESCRIBE THE NATURE OF YOUR BUSINESS (General products handled or manfactured, or nature of services performed).
8. PRINCIPAL PLACE OF BUSINESS LOCATED AT:
BRANCH(es) LOCATED AT:
9. NUMBER OF PERSONNEL PRESENTLY EMPLOYED BY YOUR FIRM
A. TOTAL
B. AT THE ADDRESS INVOLVED IN THIS PROCEEDING.
[ ]
[ ]
[ ]
10. DURING THE PAST
CALENDAR,
FISCAL YEAR (If Fiscal Year indicate dates) OR
LAST 12 MONTHS (Check appropriate box):
A.
DID GROSS REVENUE FROM SALES OR PERFORMANCE OF SERVICES DIRECTLY TO CUSTOMERS OUTSIDE THE STATE
EXCEED $50,000
[ ]
[ ]
IF LESS THAN $50,000 INDICATE AMOUNT
YES
NO
$
B.
DID GROSS AMOUNT OF PURCHASES OF MATERIALS OR SERVICES DIRECTLY FROM OUTSIDE THE STATE
[ ]
[ ]
EXCEED $50,000
YES
NO
IF LESS THAN $50,000 INDICATE AMOUNT
$
C.
DID GROSS REVENUE FROM YOUR SALES OR PERFORMANCE OF SERVICES EQUAL OR EXCEED $50,000 TO FIRMS
WHICH DIRECTLY MADE SALES TO CUSTOMERS OUTSIDE THE STATE AND/OR TO CUSTOMERS WHICH MADE
PURCHASES FROM DIRECTLY OUTSIDE THE STATE
[ ]
[
]
YES
NO
IF LESS THAN $50,000 INDICATE AMOUNT
$
D.
IF THE ANSWER TO 10(c) IS NO, DID GROSS REVENUE FROM SALES OR PERFORMANCE OF SERVICES EQUAL OR EXCEED
$50,000 TO PUBLIC UTILITIES, TRANSIT SYSTEMS, NEWSPAPERS, HEALTH CARE INSTITUTIONS, BROADCASTING STATIONS,
[ ]
[
]
COMMERCIAL BUILDINGS, EDUCATIONAL INSTITUTIONS AND/OR RETAIL CONCERNS
YES
NO
$
IF LESS THAN$50,000 INDICATE AMOUNT
E.
DID GROSS AMOUNT OF YOUR PURCHASES EQUAL OR EXCEED $50,000 FROM FIRMS WHICH IN TURN, PURCHASED THOSE
[ ]
[
]
GOODS DIRECTLY FROM OUTSIDE THE STATE
YES
NO
IF LESS THAN $50,000 INDICATE AMOUNT
$
F.
GROSS REVENUE FROM ALL SALES OR PERFORMANCE OF SERVICES (Check largest amount which firm equaled or exceeded):
[ ]
[
]
[
]
[
]
[
]
$100,000
$200,000
$250,000
$500,000
$1,000,000
IF LESS THAN $100,000 INDICATE AMOUNT
$
11. ARE YOU A MEMBER OF, OR PARTICIPATE IN, AN ASSOCIATION OR OTHER EMPLOYER GROUP THAT ENGAGES IN COLLECTIVE BARGAINING?
[ ]
[ ]
YES
NO
(If yes, give Name and Address of association or group).
12. DID FIRM PERFORM NATIONAL DEFENSE WORK DURING THE PERIOD INDICATED IN 10 ABOVE?
[ ]
[ ]
$
YES
NO
(If Yes, amount of dollar volume and name(s) and address(es) for whom work was performed).
13. PROVIDE NAME & TITLE OF YOUR REPRESENTATIVE BEST QUALIFIED TO GIVE FURTHER INFORMATION CONCERNING THE OPERATIONS OF YOUR BUSINESS
NAME
TITLE
TELEPHONE NUMBER
SIGNATURE OR AUTHORIZED REPRESENTATIVE COMPLETING THIS QUESTIONNAIRE
NAME AND TITLE (Type or Print)
SIGNATURE
DATE
PRIVACY ACT STATEMENT
Solicitation of the information on this form is authorized by the National Labor Relations Act (NLRA), 29 U.S.C. § 151 et seq. The principal use of the information is to assist
the National Labor Relations Board (NLRB) in processing representation and/or unfair labor practice proceedings and related proceedings or litigation. The routine uses for
the information are fully set forth in the Federal Register, 71 Fed. Reg. 74942-43 (Dec. 13, 2006). The NLRB will further explain these uses upon request. Disclosure of this
information to the NLRB is voluntary. However, failure to supply the information may cause the NLRB to refuse to process any further a representation or unfair labor
practice case, or may cause the NLRB to issue you a subpoena and seek enforcement of the subpoena in federal court.
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