Employer Withholding Registration

Complete all fields as it pertains to the local business

Federal ID Number *

Local Business Name *

Local Address *

Address 2

City *

State/Province *

Zip/Postal Code *

Local Phone # *

Complete all fields as they pertain to the parent company (leave this section blank if it doesn't apply)

Parent Company Name

Parent Company Mailing Address

Address 2

City

State/Province

Zip/Postal Code

Parent Company Phone #

Where should correspondence be mailed? *

Local Address

Parent Company Address

N/A

Who should we contact for withholding issues?

Contact Name *

Contact Phone # *

Contact Email *

Preferred way to contact *

Phone

Email

Any

Do you use a Payroll Service? *

Yes

No

Name of Payroll Service *

Payroll Service Contact Name *

Payroll Service Contact # *

Terms and Conditions *

By checking here, you agree to receive communication via e-mail and/or phone. You also acknowledge that the information provided above is accurate and complete to the best of your knowledge.

Name of Person Completing Registration *

E-mail Address *

Please sign *

clear