Reporting Service Details

SREG-641

1.	*	Reporting Service Type
2.		Reporting Service Federal Identification Number (FEIN) (Required if response to question 1 is not a Payroll Service)
3.	*	Reporting Service Name (Must not exceed 200 characters)
4.		Trade Name or Doing Business As
5.	*	Mailing Address
		Attention
		Care Of
		Address Line 1
		Address Line 2
		City
		State/Province
		ZIP Code
		Country
		Contact Number	-- Ext.
		E-mail Address
		Fax Number	--
6.	*	Contact Person Name
7.	*	Are you associated with another reporting service for tax and/or claims mailing purposes?	Yes No
a.	*	If Yes, provide details. (Must not exceed 512 characters)

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