TX-36  
 
                                                    (401) 574-8700 (option 1) 
                                                                   
                             EMPLOYER'S ELECTION TO COVER MULTI-STATE WORKERS 
                                                         UNDER THE 
                                      RHODE ISLAND EMPLOYMENT SECURITY LAW 
 
Employer's Firm Name _________________________________________________  RI Reg No _____________________ 
 
Address_________________________________________________________________________________________________ 
 
The  above employer hereby elects, subject to approval  by the  unemployment compensation agencies involved, to cover certain 
individuals customarily employed by him on work in more than one jurisdiction named below and on the attached sheet under the 
Employment Security Law of Rhode Island. 
 
     1) The employer accordingly requests the Employer Tax Unit to enter into a reciprocal coverage arrangement to that effect, with 
        each of the following other "interest jurisdictions" (in which the individuals named under Item 2 may do some work for the 
        employer, and under whose unemployment compensation laws they might otherwise be covered): 
                  a)__________     (d)__________  (g)__________ 
                  (b)__________  (e)__________  (h)__________ 
                  (c)__________  (f)__________  (I)__________ 
 
 To Employer:  Submit 2 signed copies for each jurisdiction listed, plus 2 more, and send all to: 
                          DEPARTMENT OF LABOR AND TRAINING 
                          EMPLOYER TAX UNIT 
                          1511 Pontiac Avenue 
                          Cranston, RI  02920-0942 
 
     2) List of workers covered by this election 
        Name _____________________________________________________ Social Security No______________________ 
 
     3) Nature of employer's business 
        ________________________________________________________________________________________________ 
 
     4) The employer has a place of business in the following states 
        ________________________________________________________________________________________________ 
 
     5) Nature of work to be performed by the individual listed. 
        ________________________________________________________________________________________________ 
 
        Basis for election in Rhode Island  
        (A) Does some work there            (B) Has residence there            (C) Related to a place of business there 
 
     6) Employer's reason for requesting coverage in Rhode Island 
        _________________________________________________________________________________________________ 
                                    
                                      1511 Pontiac Avenue, Cranston, RI 02920-0942 
                                Tel. (401) 574-8700 Fax (401) 574-8940 TTY Relay via 711 
                                        https://dlt.ri.gov/employers/employer-tax-unit 
 

     7) The employer requests that election become effective as of the beginning of a calendar quarter, namely as of  
         _________________________________________________________________________________________________ 
 
     8) This election, if approved, shall remain operative as to the individuals listed herewith until terminated in accordance with the 
         current applicable regulation of the Rhode Island Employer Tax section.   
     9) The employer hereby agrees to give each individual covered by this election a notice thereof, promptly after its approval on this 
         form, to be supplied by the Rhode Island Employer Tax Section and to file copies thereof with said agency. 
     10) To prevent this election from denying unemployment compensation coverage to workers not listed hereon, the employer hereby 
         agrees with each interested jurisdiction approving this election that it may count the workers covered by this election, and their 
         wages, as if this election did not apply, for the purpose of determining whether the employer is covered by the law of such 
         jurisdiction and whether any other workers employed by him are covered by said law. 
 
                                          1511 Pontiac Avenue, Cranston, RI 02920-0942 
                                    Tel. (401) 574-8700 Fax (401) 574-8940 TTY Relay via 711 
                                            https://dlt.ri.gov/employers/employer-tax-unit 
 

                         EMPLOYER'S ELECTION TO COVER MULTI-STATE WORKERS 
                                                UNDER THE 
                         RHODE ISLAND EMPLOYMENT SECURITY LAW 
 
Employer's Firm Name __________________________________________________    RI Reg No _____________________ 
 
Signed for this Employer 
 
by_______________________________Date_______________________________Title____________________________________ 
 
APPROVAL by Rhode Island Employer Tax Unit 
 
The foregoing election is hereby approved, in accordance with applicable regulation, as submitted by the electing employer. 
 
APPROVED for the Rhode Island Employer Tax Unit 
 
Date____________________________________By_________________________________________________________________ 
 
APPROVAL by the Interested Jurisdiction of the foregoing election is similarly approved 
              
Name of Agency _____________________________________________________________________________________________ 
 
By_________________________________________________________________________________________________________ 
 
Date___________________________________________Title_________________________________________________________             

                         1511 Pontiac Avenue, Cranston, RI 02920-0942 
                         Tel. (401) 574-8700 Fax (401) 574-8940 TTY Relay via 711 
                         https://dlt.ri.gov/employers/employer-tax-unit