Form Nys 100 - New York State Employer Registration For Unemployment Insurance, Withholding, And Wage Reporting Page 4

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NYS 100 Page 4
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. If needed, use a separate sheet of
paper.
Name
Social Security
Title
Residence Address and Phone Number
Number
2. Enter the number of physical locations at which your company operates in NYS: _____. 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:____________________________________ County: ______________________ Zip Code:________________
b. How many employees at this location? _______________
c. Check the principal activity at the above location (see Instructions):
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 principle activity is not manufacturing, indicate the products sold or service rendered:
Type of Establishment
Principal Product Sold
Percent of Total Revenue
_____________________________ _____________________________ _______________________________
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
:
E-Mail Address
_______________________________________________________________________________
* Refer to NYS – 100 I for instructions.

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