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Briefly describe the business type.
Complete the address fields below if the mailing address is different than the business address.
Enter the estimated number of workers for this business (Use a factor of 0.5 for workers regularly scheduled to work less than 20 hours per week. For all other workers (who work 21+ hours per week) use 1.0 as the factor. For example, a business with 2 Full-time employees (working 21+ hours/week) and 2 Part-time employees (working < 20 hours per week) would need to enter 3.0 for the worker count).
By checking the "I agree" box below, you agree and acknowledge that 1) I attest that, to the best of my knowledge and belief, all information in the above referenced data reported is accurate and complete. 2) you may still be required to provide a traditional signature at a later date.
This field is not part of the form submission.
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