Free 15672.pdf - Indiana

REPORT FOR SEASONAL DETERMINATION
State Form 15672 (R3 / 9-05), DWD Form 2003

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INDIANA DEPARTMENT OF WORKFORCE DEVELOPMENT 10 N. SENATE AVE., RM SE106 INDIANAPOLIS IN 46204-2277 Local: (317) 232-7436 Toll Free: 1-800-891-6499 Fax: 317-233-2706

Pursuant to Indiana Code 22-4-7-3, the undersigned Employer hereby makes application to become a Seasonal Employer for all or designated portions of its Indiana operations.

1. Indiana SUTA No.: Legal Name of Employing Unit d/b/a Business Address City Describe the nature of your business:

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FIEN:

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PO Box State ZIP Code -

2. List below the name and location of each distinct and segregable portion of your business that you wish to be claimed as Seasonal (attach additional sheets if you have more than seven (7) units). NAME A. B. C. D. E. F. G. LOCATION

3. Describe the nature of the business that you consider Seasonal under Item 2, and indicate ACTUAL DATES of Seasonal operating period (must be less than 26 weeks). NATURE OF OPERATION A. B. C. D. E. F. OPERATING PERIOD

(please complete the reverse side of this report)

REPORT FOR SEASONAL DETERMINATION (continued)
Account Number

4. List job titles or classifications which are considered Seasonal under Item 2 and the number of Seasonal employees. JOB TITLE OR CLASSIFICATIONS A. B. C. D. E. F. G. Describe any of your operations that normally extend more than 25 weeks: 5. NUMBER OF SEASONAL EMPLOYEES

6. List your job titles or classifications that normally extend more than 25 weeks.

7. I hereby certify that the foregoing information is true and correct and that I am authorized to execute this report on behalf of the employer named above.
Date Signature of Authorized Representative

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Telephone Number

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FAX Number

Title