Form Me. Fx-2 - Application For Voluntary Election

Form Me. Fx-2 - Application For Voluntary Election - 2011 Page 2

G. The undersigned, an employing unit under the Maine Employment Security Law, which has not met liability

levels of employment, voluntarily elects under Section 1222(3)(A) to become a subject employer to provide

unemployment insurance coverage for its workers effective January 1, 20_____, and to continue to be subject

to Maine Employment Security Law for not less than two (2) calendar years. Dated this _______, day of

__________________, 20____.

Name

Signature

Title

Findings by the Maine Department of Labor:

Your application for Voluntary Election of Unemployment Insurance Coverage is:

[

] APPROVED

[

] DENIED

Augusta, Maine (date)___________________Signed________________________________________

Bureau Director, Unemployment Compensation

QUESTIONS?

Contact a Representative at (207) 621-5120; TTY (Deaf / Hard of Hearing): 1-800-794-1110,

Fax at (207) 287-3733, e-mail at division.uctax@Maine.gov, or contact a Field Advisor and Examiner at one of the

numbers below:

Augusta ............(207) 621-5120

Lewiston ............(207) 753-9088

Saco..................(207) 286-2677

Bangor..............(207) 561-4094

Portland .............(207) 822-0212

Wilton ................(207) 645-5825

Brunswick.........(207) 373-4009

Presque Isle ......(207) 768-6813

Form Me. Fx-2 - Application For Voluntary Election - 2011 Page 2