Resolutions - Jersey City

~.
Form D.lice Ce.
'Rev. 3/10
STATE OF.NEW JERSEY.
DEPARTMENT 0 FTHE TREASURY .
Divisitin of P\blic Contracs Equal Employment Oprtunit Compliance
. . DUPUCA'TCERTIFICATEOF EMPLOYEE INFORMATION REPORT REQ.UEST
IMPORT ANTe FAILURE TO PROPERY COMPLETE THE ENTIRE FOIl AND. SUBMIT THE REUIRED $75.00 ÆE (Non-Refundabll!l
. .. MAY DELY ISSUANCEoF.YOUR DUPlICATE
.SECTIO
CERTIFICATE OF EMPLOYEE INfORMATION REPORT.
A . COMPANY IDENTFICAnoN
L ir NO_OR SOL SEC J . i. ASNED CETIJCATION NUIrBJ iSuiDATE . EXPIRATION DATE.
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I
i.COMPANYNAME '\\ , . 1 . .
1),mefiON ~~.J'~~lCA- ::e~.
i\c '~M.'ltt ~2r Ch(k\k &'kWr~5 ~.?&~'l?
s. ll50NFOR REUET OF DUPICATE CEHTIFiCATE ., . , .. ..
01.I.Celibiè D2.Domaø ~i.Ot..(Sodry .ie.N€.~L '
.6. NAME OF PE~N COMPLE11G FORM (pri! or T)e)
. \1, ~e. . .\- \JMc iJ
I cerif tliit the Infonationonths FDnn Is tre lind co.
SEi:ON C . OFFICIAL U5f ONLY
IlEMOAYEi I
.- . .
I. tH~S1ON OF REUEOLN#; I
.
, .1
INSTRUCTIONS FORCOPLEGDUPlIC.ATE aRTICATE REQUES
.ITE,1- Ererthe f=eiemldercat Numtir assign by thelntmBI Revenue Servce, or If a F~era Emoyer ldenlificatior
Numbe has ben applie fO, or ñ your busines Is sUC that you have nol or W1l1not receive a Federa Employr Identfcatlon
Numbe, ertertt Soal5erUy Numer of the ower or of one partr. in lllecase ora partnership. .
IT 2" Eter th Certcate Number thi was assigne ki your company alon with the Issue Date and Expiraon Date (If
aiiallable).
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Il 3 - Ener lhe name by which the copan Is Idantf.
ITE 4- Ener the physicalloclion of the copany. Include City. Conty, Staleiind .rip Code,
ITE 5 -Enerttl rean for ~esting a Duplicate Ceitllcale of Employee Information Reprt.
ITE6' Print or type the name of the pin conile~rig tte form, Incude Ihe signature, IiUe and dat.
ITE 7 - Ener it phyicallolon whee th form is being complet .
I
Include Cit, State, ZIp Cod and Phne Nuirer.
RETAI A coPy OF THIS REQUES FOR Tlvi;~'SOWH FILEAND FORWARD ONE COP wiri A CHEC IN 'TE AMOUNT OF
$75.00 (Non-Refundab!e Fet\ PAYABLE TO -THE IRSURER STAlE OF NEW JERËY TO:
NJ Deparlent of th~ Treasury
Division orPubii~ Contract
Equal Eiiployment Opportnity CoinpülUce
.. PO Box 206
Trenton, New JeryOB6iS-206. . Telehone No. (609) 292-5473
PlESI AllOw, S BI.NES DAYS FOR PROCESSIG THE DUPUCA1E CERCA TE