State Form 15672 - Report For Seasonal Determination - 2003 Page 2
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1
2REPORT FOR SEASONAL DETERMINATION
(continued)
Account Number
4. List job titles or classifications which are considered Seasonal under Item 2 and the number of Seasonal employees.
JOB TITLE OR CLASSIFICATIONS
NUMBER OF SEASONAL EMPLOYEES
A.
B.
C.
D.
E.
F.
G.
Describe any of your operations that normally extend more than 25 weeks:
5.
6. List your job titles or classifications that normally extend more than 25 weeks.
7. I hereby certify that the foregoing information is true and correct and that I am authorized to execute this report on behalf
of the employer named above.
Date
(
)
-
Signature of Authorized Representative
Telephone Number
(
)
-
Title
FAX Number
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