Form Ems 5203 - Voluntary Election To Extend The Coverage Of The Washington Employment Security Act Page 2

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PLEASE LIST ALL CURRENT OFFICERS DATA BELOW
LAST NAME
FIRST NAME
INITIAL
SOCIAL SECURITY NUMBER
NAME
STREET OR ROUTE NUMBER
CITY
STATE
RESIDENCE
A
ADDRESS
TITLE
EFFECTIVE DATE*
RESIDENCE PHONE
LAST NAME
FIRST NAME
INITIAL
SOCIAL SECURITY NUMBER
NAME
STREET OR ROUTE NUMBER
CITY
STATE
RESIDENCE
B
ADDRESS
TITLE
EFFECTIVE DATE*
RESIDENCE PHONE
LAST NAME
FIRST NAME
INITIAL
SOCIAL SECURITY NUMBER
NAME
STREET OR ROUTE NUMBER
CITY
STATE
RESIDENCE
C
ADDRESS
TITLE
EFFECTIVE DATE*
RESIDENCE PHONE
NAME OF
CORPORATE
LAST NAME
FIRST NAME
INITIAL
SOCIAL SECURITY NUMBER
OFFICERS
NAME
STREET OR ROUTE NUMBER
CITY
STATE
RESIDENCE
D
ADDRESS
TITLE
EFFECTIVE DATE*
RESIDENCE PHONE
LAST NAME
FIRST NAME
INITIAL
SOCIAL SECURITY NUMBER
NAME
STREET OR ROUTE NUMBER
CITY
STATE
RESIDENCE
E
ADDRESS
TITLE
EFFECTIVE DATE*
RESIDENCE PHONE
LAST NAME
FIRST NAME
INITIAL
SOCIAL SECURITY NUMBER
NAME
STREET OR ROUTE NUMBER
CITY
STATE
RESIDENCE
F
ADDRESS
TITLE
EFFECTIVE DATE*
RESIDENCE PHONE
* DATE OF APPOINTMENT AS CORPORATE OFFICER (MONTH & YEAR ONLY)
WAC 192-300-170 Requirements for election of unemployment insurance coverage.
(5) The department reserves the right to disapprove an election of unemployment insurance coverage due to:
(a) The applicant being non-liable for federal unemployment taxes (FUTA); or
(b) the seasonal nature of the occupation or industry.
(6) The department reserves the right to cancel unemployment insurance coverage for a voluntary election employer because:
(a) of nonpayment of unemployment insurance taxes, and/or failure to file an unemployment insurance tax/wage report; or
(b) of misrepresentation of facts; or
(c) coverage is not used for involuntary unemployment as outlined in RCW 50.01.010.

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