Organization *

DBA *

FEIN # *

First Name

Last Name

Email

Phone

Type Of Establishment (ie Full Service, Fast Food, Bar) *

Estimated Annual Payroll: Restaurant Employees *

(minus tips)

Estimated Annual Payroll: Clerical Employees (if any)

Estimated Annual Payroll: Executive Officers (if covered under workers' comp)

Payroll Company (if any)