Form C-1 - Status Report Page 2
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28. VERMONT PHYSICAL LOCATION WHERE SERVICES ARE PERFORMED (ATTACH ADDITIONAL SHEET, IF NECESSARY
STREET ADDRESS (NO P.O. BOXES)
TELEPHONE NUMBER
CITY
STATE
ZIP
FAX NUMBER
VERMONT
9. HAVE YOU EVER HAD A VERMONT UNEMPLOYMENT ACCOUNT NUMBER?
NO
YES
SPECIFY ACCOUNT NUMBER:
10. DO YOU HAVE WORKER PERFORMING SERVICES FOR YOUR BUSINESS WHOM YOU CONSIDER TO BE SELF-EMPLOYED OR INDEPENDENT CONTRACTORS?
NO
YES
IF YES, PLEASE ATTACH A LIST PROVIDING NAME, ADDRESS, PHONE AND TYPE OF SERVICES PROVIDED/PERFORMED.
11. DID YOU ACQUIRE THE ORGANIZATION,
11A. DID YOU ACQUIRE
ALL
PART
11B. DATE ACQUIRED
TRADE, BUSINESS OR ANY ASSETS OF
ANY OTHER VERMONT EMPLOYER?
11C. NAME OF BUSINESS ACQUIRED
11D. UNEMPLOYMENT ACCT. OF BUSINESS ACQUIRED
YES - COMPLETE ITEMS 11A-11F
NO - GO TO ITEM 12
11E. NUMBER OF EMPLOYEES RETAINED
NONE
SOME
ALL
HOW MANY?
DID YOU INCORPORATE YOUR VERMONT
FROM FORMER OWNER
PROPRIETORSHIP OR PARTNERSHIP?
YES - ACCOUNT NO:______________
11F. HOW WAS BUSINESS ACQUIRED?
(CHECK ONE)
NO - GO TO ITEM 12
PURCHASE
MERGER
FRANCHISE
LEASE
OTHER, EXPLAIN:__________________________
NATURE OF BUSINESS ACTIVITY
DESCRIBE FULLY THE NATURE OF ACTIVITY
12A.
IN VERMONT
LIST PRINCIPLE PRODUCT(S) OR SERVICE(S),
12B.
IN ORDER OF IMPORTANCE
SELECT ONE OF THE SHORT TITLES BELOW, WHICH MOST CLOSELY DESCRIBES YOUR BUSINESS IN VERMONT AND ENTER THE
INDUSTRY CODE NUMBER
12C.
APPROPRIATE CODE IN THE SPACE PROVIDED.
CODE
SHORT TITLE
CODE
SHORT TITLE
CODE
SHORT TITLE
Agriculture, Forestry, Fishing & Hunting
424 Merchant Wholesalers, Nondurable Goods
525 Funds, Trusts & Other Financial Vehicles
111 Crop Production
425 Wholesale Electronic Markets & Agents & Brokers
Real Estate & Rental & Leasing
112 Animal Production
Retail Trade
531 Real Estate
113 Forestry & Logging
441 Motor Vehicles & Parts Dealers
532 Rental & Leasing Services
114 Fishing, Hunting & Trapping
442 Furniture & Home Furnishing Stores
533 Lessors or Other Nonfinancial Intangible Assets
115 Support Activities for Agriculture & Forestry
443 Electronics & Appliances Stores
Professional, Scientific & Technical Services
Mining
444 Bldg. Material & Garden Supply Stores
541 Professional, Scientific & Technical Services
211 Oil & Gas Extraction
445 Food & Beverage Stores
Management of Companies & Enterprises
212 Mining (except Oil & Gas)
446 Health & Personal Care Stores
551 Management of Companies & Enterprises
213 Support Activities for Mining
447 Gasoline Stations
Administrative & Waste Services
Utilities
448 Clothing & Clothing Accessories Stores
561 Administrative Support Services
221 Utilities
451 Sporting Goods, Hobby, Book & Music Stores
562 Waste Management & Remediation Services
Construction
452 General Merchandise Stores
Educational Services
236 Construction of Buildings
453 Miscellaneous Store Retailers
611 Educational Services
237 Heavy & Civil Engineering Construction
454 Nonstore Retailers
Healthcare & Social Assistance
238 Specialty Trade Contractors
Transportation & Warehousing
621 Ambulatory Healthcare Services
Manufacturing
481 Air Transportation
622 Hospitals
311 Food Mfg.
482 Rail Transportation
623 Nursing & Residential Care Facilities
312 Beverage & Tobacco Product Mfg.
483 Water Transportation
624 Social Assistance
313 Textile Mills
484 Truck Transportation
Arts, Entertainment & Recreation
314 Textile Product Mills
485 Transit & Ground Passenger Transportation
711 Performing Arts, Spectator Sports & Related Ind.
315 Apparel Mfg.
486 Pipeline Transportation
712 Museums, Historical Sites & Similar Institutions
316 Leather & Allied Product Mfg.
487 Scenic & Sightseeing Transportation
713 Amusement, Gambling & Recreation Industries
321 Wood Product Mfg.
488 Transportation Support Activities
Accommodation & Food Services
322 Paper Mfg.
491 Postal Service
721 Accommodations
323 Printing & Related Support Activities
492 Couriers & Messengers
722 Food Services & Drinking Places
324 Petroleum & Coal Products Mfg.
493 Warehousing & Storage
Other Services (except Public Administration)
325 Chemical Mfg.
Information
811 Repair & Maintenance
326 Plastics & Rubber Products Mfg.
511 Publishing Industries (except internet)
812 Personal & Laundry Services
327 Nonmetallic Mineral Product Mfg.
512 Motion Picture & Sound Recording Industries
813 Membership Associations & Organizations
331 Primary Metal Mfg.
515 Broadcasting (except internet)
814 Private Households
332 Fabricated Metal Product Mfg.
516 Internet Publishing & Broadcasting
Public Administration
333 Machinery Mfg.
517 Telecommunications
921 General Government Administration
334 Computer & Electronic Product Mfg.
518 ISP's, Search Portals & Data Processing
922 Justice, Public Order & Safety Activities
335 Electrical Equip., Appliance & Component Mfg.
519 Other Information Services
923 Administration of Human Resource Programs
336 Transportation Mfg.
Finance & Insurance
924 Administration of Environmental Programs
337 Furniture & Related Product Mfg.
521 Monetary Authorities - Central Bank
925 Community & Housing Program Administration
339 Miscellaneous Mfg.
522 Credit Intermediation & Related Activities
926 Administration of Economic Programs
Wholesale Trade
523 Financial Investment & Related Activities
927 Space Research & Technology
423 Merchant Wholesalers, Durable Goods
524 Insurance Carriers & Related Activities
928 National Security & International Affairs
13. 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
EXCLUDE: Locations that are temporary (exist less than 1 year) or are not staffed on a regular basis.
NUMBER OF WORKERS AT EACH LOCATION.
14. PERSON IN POSSESSION OF PAYROLL RECORDS
TITLE
PHONE
FAX
15. SIGNATURE OF OWNER, PARTNER, OFFICER, HEAD OF HOUSEHOLD, TRUSTEE
TITLE
DATE
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