Form Nucs-4557 - Magnetic Media Application - Wage Data - Nevada Department Of Employment
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1STATE OF NEVADA
DEPARTMENT OF EMPLOYMENT, TRAINING AND REHABILITATION
EMPLOYMENT SECURITY DIVISION
500 EAST THIRD ST.
CARSON CITY, NEVADA 89713-0300
(775) 687-4487
MAGNETIC MEDIA APPLICATION
WAGE DATA
Name of Firm Making Request:
Address:
City, State, Zip Code:
Name of Contact for Technical Information:
Title:
Telephone:
Name of Contact for Payroll Information:
Title:
Telephone:
List firm(s) that will reported on the submitted media. Each Firm/Employer Name must be accompanied by the
employer’s Nevada Employment Security Division Account Number. (Attach additional sheets if necessary.)
Employer Account Number
Employer Name
Indicate the Calendar Quarter in which you plan to begin reporting:
Reel/Cartridge Information
Diskette Information
Computer: Manufacturer Model
Operating System:
Record Size:
Block Size:
Type of Label (check one)
Standard ( )
Non-Standard ( )
Diameter:
3½" ( )
Code:
ASCII ( )
EBCDIC ( )
Capacity:
Sides/Density:
Tracks Per Inch:
Sector Size:
_________________________________________________________________
___________________________________
Signature/Title
Date
NUCS-4557 (Rev. 9/2000)
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