Maryland New Hire Registry                   Reporting Form     
Send completed forms to:                                          To ensure the highest level of accuracy, please print neatly in 
Maryland State Directory of New Hire  s                           capital letters and avoid contact with the edges of the boxes.  
PO Box 1316                                                       The following will serve as an example: 
Baltimore, MD  21203-1316                                         A B C                     1             2 3 
Fax: (410) 281-6004 or toll-free fax 1 (888) 657-3534 

                                        EMPLOYER INFORMATION  
Federal Employer Id Number (FEIN :)                               State Unemployment Insurance Number (MD Only SUIN): 

Please use the same FEIN  that appears on quarterly wage reports. If SUIN not issued yet, please write “APPLIEDFOR” in 
Employer Name:                                                    the above box. If Exempt, write “EXEMPT”. 

Employer Address (Please indicate the address where the Income Withholding Orders should be sent): 

Employer City:                                                        Employer State:  Zip Code (5 digit): 

Employer Phone (optional):                                        Employer Fax (optional): 

Contact Name (optional): 

Email (optional): 

                                        EMPLOYEE INFORMATION  
Employee Social Security Number (SSN):                                Date of Hire (mm/dd/yyyy): 

Employee First Name:                                                                                      Middle Initial 
                                                                                                            (optional): 

Employee Last Name: 

Employee Address: 

Employee City:                                                      Employee State:         Zip Code (5 digit): 

Date of Birth mm/dd/yyyy (optional):    Employee Salary (Dollars and Cents): Hourly      Monthly     Yearly 

Are health care benefits available to employee? (Y/N):              Employee Gender (M)ale/(F)emale: 

                     Reports must be submitted within 20 days of the date of hire or rehire                 Rev (09/02) 
Questions?  Call us at (410) 281-6000 or toll-free 1 (888) MDHIRES (634-4737).   Report online at www.mdnewhire.com