Electronic Media Transmittal Form - Georgia Department Of Labor Page 6

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GEORGIA DEPARTMENT OF LABOR
ELECTRONIC MEDIA TRANSMITTAL FORM
For Non-Payroll Services
Check here if this is test media.
Check here if a Tax Report (N Record) is included.
TRANSMITTER INFORMATION
Name of Transmitter:
Telephone Number:
Date:
Street Address of Transmitter:
Contact Person:
City, State, Zip Code:
Contact’s Email Address:
EMPLOYERS REPORTED
Employer Name
Account #
# of Records
Employer Name
Account #
# of Records
MEDIA TYPE and QUANTITY
(All media must contain an external label)
DVD-Rom/qty.
CD-Rom/qty.
Floppy/qty.
Zip Disk/qty.
For Questions and Technical Assistance
Mail Electronic Media To
Telephone
(404) 232-3265
Georgia Department of Labor
Fax
(404) 232-3268
Magnetic Media Unit
Email
magneticmedia@dol.state.ga.us
Suite 727A
148 Andrew Young International Blvd., N.E.
Atlanta, Georgia 30303-1751

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