North Dakota > Workers Comp
Employer Registration SFN 53215 - North Dakota
| Employer Registration Form. This is a North Dakota form and can be used in Workers Comp . |
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EMPLOYER REGISTRATION RETURN TO WORK DIVISION SFN 53215 (05/2008) 1600 EAST CENTURY AVENUE, SUITE 1 PO BOX 5585 BISMARCK ND 58506-5585 TELEPHONE 1-800-777-5033 Toll Free Fax 1-888-786-8695 TTY (hearing impaired) 1-800-366-6888 Fraud and Safety Hotline 1-800-243-3331 www.WorkforceSafety.com EMPLOYER INFORMATION Company Name Street Address Phone Number WSI Account Number City, State, and Zip Code Contact Person JOB INFORMATION Job Title Address of Job Site (if different than listed above) Required Education (list degrees or formal training) Required Licenses/Certificates Necessary Experience Wage City, State, and Zip Code (if different than listed above) Hours Per Week Closing Date Job Description (please be specific to include all physical demands) Check one: Full-time Part-time Temporary To Apply American LegalNet, Inc. www.FormsWorkFlow.com
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