Form Bls 3023-Nvm - Industry Verification Form printable pdf download

Form Bls 3023-Nvm - Industry Verification Form

Arkansas Dept of Workforce Services

Industry Verification Form, BLS 3023-NVM

BLS Programs

Form Approved, O.M.B. No. 1220-0032

P O Box 2981

Expiration Date: 12/31/2017

Li ttle Rock AR 72203-2981

In cooperation with the U.S. Department of Labor

P hone: (501) 682-6581

F AX: (501) 682-2942

Unemployment Insurance Account Number:

________________________________________ in Arkansas.

This report is authorized by law, 29 U.S.C. 2. Your cooperation is needed to make the results of this survey

complete, accurate, and timely. Purpose, use and help information are located on the back of this form.

We appreciate your response within 14 days. Thank you.

BUSINESS MAILING ADDRESS

Please print.

Business Name: _______________________________________________________________________________

Street Address: ________________________________________________________________________________

City: __________________________________________________ ST: ___________________ ZIP: __________

MAIN BUSINESS ACTIVITY OF EACH LOCATION ADDRESS

In Section A, please provide a list of all worksites of your business within the state. Please make sure to

provide the physical location address for each worksite, along with a brief description of the main business

activity at each location. Further instructions are printed in Section A.

CONTACT INFORMATION

Name: _______________________________________________________

Date: ____________________

Title: ________________________________________________________

Phone: ___________________

Email: _____________________________________________________________________________________

Website: ___________________________________________________________________________________

You may return this form via FAX: (501) 682-2942 or by mail:

Arkansas Dept of Workforce Services

BLS Programs

PO Box 2981

Little Rock, AR 72203-2981

Form Bls 3023-Nvm - Industry Verification Form