Form Nys-100 - New York State Employer Registration For Unemployment Insurance, Withholding, And Wage Reporting - 2013 Page 3

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NYS 100 page 3
Legal Name: __________________________________ER Number: _________________________
Part E – Business Information
1. Complete the following for sole proprietor (owner), household employer of domestic services, all partners,
including partners of LP, LLP or RLLP, all members of LLC or PLLC, and corporate officers (President, Vice
President, etc.), whether or not remuneration is received or services are performed in New York State.
Name
Social Security
Title
Residence Address
Number
2. Please enter the number of physical locations at which your company operates: _____. You MUST list the physical
address and answer questions A through E below, for each location. Use a separate sheet of paper for each.
a. Location: _______________________
____________________
_____________________
___________
Number and Street
City or Town
County
Zip Code
b. Approximately how many persons do you employ there? _______________
c. Check the principal activity at the above location:
Manufacturing
Transportation
Scientific/professional & technical services
Wholesale trade
Computer services
Finance & insurance
Retail trade
Educational services
Arts, entertainment & recreation
Construction
Health & social assistance
Food service, drinking & accommodations
Warehousing
Real estate
Corporate, subsidiary managing office
Other (Please specify):_____________________________________________________________________
d. If you are primarily engaged in manufacturing, complete the following:
Principal Products Produced
Percent of Total Sales Value
Principal Raw Materials Used
____________________________
__________________________
_________________________
e. If your principal activity is not manufacturing, indicate products sold or services rendered:
Type of Establishment
Principal Product Sold or
Percent of Total Revenue
Service Rendered
_____________________________
__________________________
________________________
I affirm that I have read the above questions and that the answers provided are true to the best of
my knowledge and belief.
/
/
X
________________________________________________________________
Signature of Officer, Partner, Proprietor, Member or Individual
(mm/dd/yyyy)
(
)
-
_______________________________________________ Phone no.:
Official Position
* Refer to NYS – 100 I for instructions.

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