Mississippi Department of Employment Security  ||M M| |D D| E || E|S  | S |
      UI-1 
                                                               STATUS REGISTRATION 
                                                                                                  
                                                                Please type or print. Always complete entire form.                       
                                                                                                  
 MDES OFFICIAL INFORMATION                                                                                                          Found Date (MM/DD/CCYY): 
                                                                                                  
                                                                                       DO NOT WRITE ABOVE THIS LINE.  
 EMPLOYER ENTITY INFORMATION 
   1. Federal Employer ID Number (FEIN):               -
   2. Organization Type:                    F Corporation          F                   Partnership            F    Individual         F     Non-Profit Corp. 
                                                                                                                                       
                                           F Corporate LLC         F  Partnership LLC                         F   Individual LLC      F  Other (enter type):      
   3. IF A CORPORATION: a. State of Incorporation:                                    b. Date of Incorporation (MM/DD/CCYY):                                          c. State of Legal Domicile: 
   4. IF INDIVIDUAL OWNER:  
       Do you employ any individual(s) not including yourself, your spouse or your children under 21 years of age?   YES  F      NO  F            
   5. Legal Entity Name:                                                                                        6. Business Name (D/B/A):         
   7. Have you paid employees for work performed in Mississippi?              YES                               F      NO  F        7. a.  If Yes, provide the date (MM/DD/CCYY) you first 
                                                                                                                                    employed someone in Mississippi: 
   8. Does this business consist solely of agricultural work?       YES  F      NO  F            
   9. Does this business employ domestic help?                          YES  F     NO  F  (This includes housekeepers, sitters, or other domestic employment) 
 10. Are you applying for reimbursable status under the Indian Tribal Law?              YES  F      NO F    
 11. Is this organization a State College, State University or State Hospital?             YES  F      NO F    
 12. Is this business FUTA (Federal Unemployment Tax) liable in another state?     YES  F      NO F 
 13. Are you a Professional Baseball Concessionaire?                                              YES  F      NO F 
 14. Do you have a Third Party that handles your payoll and/or tax matters?            YES  F      NO F 
   a. If Yes, Third Party authorized to handle matters for Unemployment Tax:                                                   b. Agent/Officer Phone:      
       Name:        
       Title:                                                                                                                       (            )                 -                ext.  
 15. Do you have business location(s) in Mississippi?                                                YES  F      NO F 
    a. If Yes, list below your places of business in Mississippi and give a description of your operations at each place of business. 
              City                                County                                 Number of Employees                                Principal Business Activity 
     
 16. Are you exempt as an IRS 501 (C) (3) Non-Profit Organization?           YES F      NO F                                   a. If Yes, attach a copy of your 501(C) (3) exemption. 
                                                                                                  
 EMPLOYER CONTACT DETAILS 
 1. Physical Address    
  
     Address: 
     City:                                                                               State:                            Country:                                   ZIP Code: 
     Phone:        (            )                 -                
 2. Unemployment    Tax Mailing Address        Same as previous  F   
     
      Attention: 
     Address: 
     City:                                                                               State:                            Country:                                   ZIP Code: 
    Phone:  (            )                 -                 
    Contact Name (First, MI, Last):                                                      Phone:   (          )                 -                ext. 
 3. Unemployment Claims Mailing Address   Same as previous  F   
  
     Address: 
     City:                                                                               State:                            Country:                                   ZIP Code: 
     Phone:   (            )                 -                                                                FAX:   (            )                 -                 
                                                                                                                                                                                                   
                                                                  Mississippi Department of Employment Security is an equal opportunity employer.                                         UI-1 R-12/2006 
Web Address: www.mdes.ms.gov                                   Auxiliary aids and services are available upon request to individuals with disabilities.                                   Page 1 of 3 

   UI-1                                                                                  STATUS REGISTRATION                                                                          2
 
4. Payroll Mailing Address                           Same as previous  F   
 
    Address: 
    City:                                                                                 State:          Country:                              ZIP Code: 
    Phone:   (            )                 -                                                        FAX:   (            )                 -                 
5. Officer or Resident Agent authorized to furnish payroll information: 
    Name: 
    Title: 
6. Preferred Mode of Correspondence:   F  USPS          F  E-Mail          F  Telephone          F  FAX        F  Other (enter type): 
7. Employer E-Mail Address: 
 
BUSINESS OWNERSHIP 
1. List the Name, Title, Social Security Number and Address of the Proprietor, Partners or Corporate Officers. 
             NAME (First, MI, Last)                                                 TITLE             SSN                                                    ADDRESS
 
                                                                                                     -           -                                                 
                                                                                                     -           -                                                 
 
                                                                                                     -           -                                                 
 
2. Beginning Date of Employment in Mississippi (MM/DD/CCYY):                                                               3. Date Acquired (MM/DD/CCYY):                        
4. Did you acquire (purchase, inherit, etc) this business                            ?           Yes F      NoF         If yes, provide details about the previous owner below. 
    a. Name this business was operating under (Doing Business As):                                                      b. Federal Employer Identification Number (FEIN) 
                                                                                                                                   -  
    c. Previous Owner’s Current Address:                                                                                d. MDES Employer Account Number (EAN): 
                                                                                                                                   -                       -        -   
    e. Phone:     (            )                 -                ext. 
    f.  Does this business continue to operate?                                           Yes F      No F            
       
5. Have you ever been registered with the Mississippi Department of Employment Security?      Yes F      No F 
   a.  If Yes, provide previous MDES Employer Account Number (EAN):           -                       -        -   
     b.  If Yes, provide previous Federal Employer Identification Number (FEIN):         - 
 
LAST CALENDAR YEAR 20____ 
 Indicate in each space the TOTAL WAGES you paid during each calendar quarter in the Last Calendar Year. 
           1st Quarter                                        2nd Quarter                                          3rd Quarter                                    4th Quarter 
                                                                                       
Each box represents a Calendar Week. Indicate by Calendar Week the number of people working for you during each week of the Last Calendar Year. 
1st        2nd     3rd                      4th  5th                                6th   7th        8th          9th   10th               11th              12th  13th         14th
                        
15th       16th    17th                     18th 19th                               20th  21st       22nd         23rd  24th               25th              26th  27th         28th
                        
29th       30th    31st                     32nd 33rd                               34th  35th       36th         37th  38th               39th              40th  41st         42nd
                        
43rd       44th    45th                     46th 47th                               48th  49th       50th         51st  52nd               53rd              xx    xx           xx
                                                                                                                                                                                 
CURRENT CALENDAR YEAR 20____ 
Indicate in each space the TOTAL WAGES you paid during each calendar quarter in the Current Calendar Year. 
           1st Quarter                                        2nd Quarter                                          3rd Quarter                                    4th Quarter 
                      
Each box represents a Calendar Week. Indicate by Calendar Week the number of people working for you during each week of the Current Calendar 
Year. 
1st        2nd     3rd                      4th  5th                                6th   7th        8th          9th   10th               11th              12th  13th         14th
                        
                                                 Mississippi Department of Employment Security is an equal opportunity employer.                                       UI-1 R-12/2006 
 Web Address: www.mdes.ms.gov                    Auxiliary aids and services are available upon request to individuals with disabilities.                               Page 2 of 3 

   UI-1                                             STATUS REGISTRATION                                                                                  3
 
15th       16th    17th        18th 19th       20th 21st 22nd   23rd    24th                                                 25th 26th 27th  28th
                        
29th       30th    31st        32nd 33rd       34th 35th 36th   37th    38th                                                 39th 40th 41st  42nd
                        
43rd       44th    45th        46th 47th       48th 49th 50th   51st    52nd                                                 53rd xx   xx    xx
                                                                                                                                              
I hereby certify that all the information contained above is true and correct to the best of my knowledge. 
Date (MM/ DD /CCYY):                Firm Name: 

Signature:                                               Title: 
  
                                    Mississippi Department of Employment Security is an equal opportunity employer.                       UI-1 R-12/2006 
  Web Address: www.mdes.ms.gov      Auxiliary aids and services are available upon request to individuals with disabilities.              Page 3 of 3