Form Wh-1 - Economic Survey Schedule - 1994
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1
2U.S. Department of Labor
Economic Survey Schedule
Employment Standards Administration
Wage and Hour Division
1. Name and Address of Establishment:
OMB No. 1215-0028
(Include ZIP Code and telephone number)
Expires: 08-31-2006
2. Industry and Classification:
3. Type of business activity:
4. Source of materials:
5. Finished products: Are the finished products shipped outside of American Samoa?
Yes
No
If yes, indicate who pays the shipping costs.
6. Is firm tax exempt?
Yes
No
Pending
7. You are requested to furnish copies of balance sheets and income and expense statements for the 2 most recent years. (Income
and expense statements are held in confidence.) Attached:
No
Yes
8. Survey payroll period:
Begins
Ends
9. a. Total employment during survey payroll period:
b. Employees covered by this industry wage order:
10. Employment covered by this industry wage order (item 9b) for the 2 most recent years:
Year
Feb. 12th
May 12th
Aug. 12th
Nov. 12th
11. Collective bargaining agreement:
No
Yes
If yes, please attach a copy
12. Fringe benefits provided by establishment:
Number of paid holidays:
Health care plan
Number of paid vacation days:
Pension plan
Number of paid sick leave days:
Other (specify)
13. Additional remarks:
14. Name of person submitting information:
Title:
Date submitted:
Form WH-1
Rev. Nov 1994
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