General Information

Employer Name F.E.I.N Business Type Employment Type Phone Number Email Address Nature of Activity

Liability Information

Corporation Name Employment Start Date Wages Start Date First $1,500 Quarter 20th Week of Employment Date U.S. Citizens Employed Outside of the U.S. Current No. of Texas Employees Subject Subsection

Acquisition Information

Business Acquired

Ownership Information

Filing Number Filing State Filing Date Original Name

Registered Agent Information

Name

Officer Information

Name Social Security Number Email Address title Residence Address

Location Information

Mailing Address Phone Number Payroll records kept at this Mailing Address Location(Yes/No) YesNo

Trade Name and Physical Location

Trade Name Business Location Nature of Activity Description