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Organization Name, Address, etc.
*Legal Name
(Individual, Partnership, Corporation, LLC Name)
Attention
Trade Name
(Doing Business As - List All Names)
*Mailing Address
*Phone Number
Business Website
*City
*State
*Zip Code
Plus 4
ALABAMA
ALASKA
ARIZONA
ARKANSAS
CALIFORNIA
COLORADO
CONNECTICUT
DELAWARE
DISTRICT OF COLUMBIA
FLORIDA
GEORGIA
HAWAII
IDAHO
ILLINOIS
INDIANA
IOWA
KANSAS
KENTUCKY
LOUISIANA
MAINE
MARYLAND
MASSACHUSETTS
MICHIGAN
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MISSISSIPPI
MISSOURI
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NEW HAMPSHIRE
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NEW MEXICO
NEW YORK
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OREGON
PENNSYLVANIA
RHODE ISLAND
SOUTH CAROLINA
SOUTH DAKOTA
TENNESSEE
TEXAS
UTAH
VERMONT
VIRGINIA
WASHINGTON
WEST VIRGINIA
WISCONSIN
WYOMING
*The physical location of this business in
Nebraska
is: select one
The same as the mailing address above
No physical location in Nebraska - please explain
Different from mailing address, click on ADD to provide ALL physical addresses
If Out of State employer, are services of workers performed in Nebraska?
Yes
No
*Are you an employee leasing company/PEO?
Yes
No
If yes, your client's Nebraska workers and wages must be reported under their established Nebraska Unemployment Insurance account or you must complete this application with your client's information to establish an account in Nebraska.
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