Form De 1 - Commercial Employer Account Registration And Update Form Page 2
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1
2COMMERCIAL EMPLOYER ACCOUNT
REGISTRATION AND UPDATE FORM
000101152
F.
LOCATION OF
Do you have employees working in California?
Yes
No
EMPLOYEE
SERVICES
Do you have employees residing in California that are working outside of California?
Yes
No
G. INDIVIDUAL
CA Driver
NAME
TITLE
SSN
License
Add Chg. Del.
OWNER/
Number
CO-OWNER
INFORMATION
(If applicable)
H. CORPORATE
CA Driver
NAME
TITLE
SSN
License
Add Chg. Del.
OFFICER(S),
Number
PARTNERS, OR
LLC MEMBER(S),
MANAGER(S),
AND/OR
OFFICER
INFORMATION
I.
LEGAL NAME OF ORGANIZATION (Corporation/LLC/LLP/LP: Enter exactly as it appears on your official registration documents.)
J.
DOING BUSINESS AS (DBA) (If applicable)
K. FEDERAL EMPLOYER IDENTIFICATION NUMBER (FEIN)
L.
DATE OWNERSHIP BEGAN (MM/DD/YYYY)
____/____/______
M. STATE OR PROVINCE OF INCORPORATION/ORGANIZATION
N. CALIFORNIA SECRETARY OF STATE ENTITY NUMBER
O. PHYSICAL BUSINESS
Street Number
Street Name
Unit Number (If applicable)
LOCATION
(PO Box or Private
City
State/Province
ZIP Code
Country
Mail Box will not be
accepted.)
Business Phone Number
P.
MAILING ADDRESS
Street Number
Street Name
Unit Number (If applicable)
(PO Box or Private Mail
Box is acceptable.)
City
State/Province
ZIP Code
Country
Same as above
Phone Number
Q. E-MAIL
Valid E-mail Address
Check to allow
e-mail contact.
R. INDUSTRY ACTIVITY
Describe in detail your specific product/services:
Select your business industry
Services
Retail
Wholesale
Manufacturing
Temporary Services
Leasing Employer
Professional Employer Organization
Other (Specify) _____________________
S. CONTACT PERSON
Name
Contact Phone Number
E-mail Address
(Complete a Power of
Attorney [POA] Declaration
Relation
Address
[DE
48], if applicable.)
T.
DECLARATION
I certify under penalty of perjury that the above information is true, correct, and complete, and that
these actions are not being taken to receive a more favorable Unemployment Insurance rate. I further
certify that I have the authority to sign on behalf of the above business.
Signature
Date
Name
Title
Phone Number
MAIL TO: EDD, Account Services Group, MIC 28, PO Box 826880, Sacramento, CA 94280-0001
PRINT
DE 1 Rev. 79 (3-16) (INTERNET)
Page 2 of 2
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