Request For Employers Change Of Address {DOL-2867T}

GEORGIA DEPARTMENT OF LABOR 148 Andrew Young International Blvd., Suite 850 Atlanta, Georgia 30303 Phone (404) 232-3001 -Fax (404) 232-3285 REQUEST FOR EMPLOYER'S CHANGE OF ADDRESS GDOLAccount N u m b e r - - - - - - - - - - - - - - FederaiiD Number _ _ _ _ _ _ _ _ _ _ _ _ _ __ Employer N a m e - - - - - - - - - - - - - - - - Mailing Address Company Name _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ Address _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ City _ _ _ _ State _ _ Zip Code _ _ _ County _ _ __ Company E-mail address _ _ _ _ _ _ _ _ _ _ _ _ __ Telephone No. _ _ _ _ _ _ Fax No. _ _ _ _ _ _ _ __ Principle Business Location in GA Address _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ City _ _ _ _ _ _ _ State _ _ Zip Code _ _ __ Company E-mail address _ _ _ _ _ _ _ _ _ __ Telephone No. _ _ _ _ _ Fax No. _ _ _ _ _ _ __ Additional Addresses: Service Provider/Quarterly Tax and Wage Reports Service Provider's N a m e - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Address _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ City _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ State _ _ _ Zip C o d e - - - - - - - - - - - - - Company E-mail a d d r e s s - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Telephone No. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ FaxNo. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ Claims Notification Address Address _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ City _ _ _ _ _ _ _ _ state __ Zip Code _ _ _ _ __ Telephone No. _ _ _ _ _ _ Fax No. _ _ _ _ _ _ _ __ Tape and Diskette Return Contact _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ Address _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ City _ _ _ _ _ _ _ State _ _ Zip Code _ _ __ Company E-mail _ _ _ _ _ _ _ _ _ _ _ _ __ Telephone No. _ _ _ _ _ Fax No. _ _ _ _ _ __ Address for Employer Quarterly Notice of Benefit Charges, DOL-620 Address _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ City _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ State _ _ _ ZipCode _ _ _ _ _ _ _ _ _ _ _ _ __ Telephone No. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Fax No. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ 1 understand that all notifications to the employer, with the above Georgia Department of Labor account number, will be sent to the designated addresses listed above. Date _ _ _ _ _ _ _ _ Telephone No. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ Signature _ _ _ _ _ _ _ _ _ _ _ _ Print Name and Title _ _ _ _ _ _ _ _ _ _ _ __ American LegalNet, Inc. www.FormsWorkFlow.com DOL-2867T (8/05)