Reporting Service Details

SREG-641

1.	*	Reporting Service Type
2.	*	Reporting Service Federal Identification Number (FEIN).
3.	*	Reporting Service Name (Must not exceed 200 characters)
4.		Trade Name or Doing Business As
5.	*	Mailing Address
		Attention
		Care Of
		Address Line 1
		Address Line 2
		City
		State/Province
		ZIP Code
		Country
		Contact Number	-- Ext.
		E-mail Address
		Fax Number	--
6.	*	Contact Person Name
7.	*	Are you associated with another reporting service for tax and/or claims mailing purposes?	Yes No
a.	*	If Yes, provide details. (Must not exceed 512 characters)

Attention: Each payroll company/provider (as a legal entity) is only allowed one Third Party account and one Payroll Service account. Please do not reapply to be a Payroll Service or Third Party if you already have one of the said account. Continued attempts to reapply will be denied.

Example: ABC Wyoming can have one of each of the above referenced accounts, and ABC Colorado can have one of each of the above referenced accounts. This only applies if the companies are separate legal entities.

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