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 UIA 1155                                                                                                                              Authorized by
 (Rev. 09-17)                                                                                                                     MCL 421.1 et seq.

                                                                  STATE OF MICHIGAN
    GRETCHEN WHITMER               DEPARTMENT OF LABOR AND ECONOMIC OPPORTUNITY            JEFF DONOFRIO
                GOVERNOR                                                             UNEMPLOYMENT INSURANCE AGENCY                 DIRECTOR

                         Application for Designation as Seasonal Employer
COMPLETE THE FOLLOWING INFORMATION ABOUT YOUR BUSINESS:
Name of Employer:___________________________________________________     Employer Account No.:_________________________

DBA:______________________________________________________________     FEIN Number:________________________________
Mailing                                                                Date You Began
Address:___________________________________________________________     Business in Michigan:__________________________

City, State, Zip:______________________________________________________     SIC Code:___________________________________
                                                                                                                   For UI Use Only
COMPLETE THE FOLLOWING TABLE:
If you have operated this business in Michigan for at least 1 season, give the beginning and ending dates of your seasonal work periods 
for each season you have operated, up to 5 seasons; also give the total number of workers you employed in Michigan during each of those 
seasonal work periods, and the total number of workers you employed in Michigan during the week the season ended and the prior 51 
weeks. Count all workers regardless of how few days or hours they may have worked for you during the season. You may designate a normal 
seasonal work period in the space provided below the table, or one will be assigned by Unemployment Insurance based either on the earliest 
beginning and latest ending dates you have provided or, if that is more than 26 weeks, then based on your most recent seasonal work period.
If you have already been designated as a seasonal employer and wish to change your seasonal work period, please check here......
If you have not operated this business before in Michigan, disregard the table; instead, indicate your expected normal seasonal work period, 
up to 26 weeks. From _________________________ through _________________________.

                                                                                                                                  Total Workers in 52 
 Past 5 Completed         Date Season Began                 Date Season Ended      Number of Seasonal                             Weeks Including the 
        Seasons           (Month, Day, Year)                (Month, Day, Year)     Workers                                        Week Each Season 
                                                                                                                                       Ended
 Last Season
 2 Seasons Ago
 3 Seasons Ago
 4 Seasons Ago
 5 Seasons Ago

Within the period from the earliest beginning date of any season to the latest ending date of any season, 
shown above, what period (up to 26 weeks) do you wish to designate as your normal seasonal work period? 
From ______________________ through _____________________.

CERTIFICATION:
I certify that the information I have given on this application form is accurate and complete to the best of 
my knowledge and belief. I understand that the designation of this employer as seasonal can be revoked if 
information on this form is inaccurate, and that criminal penalties under Section 54 of the Michigan Employment 
Security Act can be imposed if false statements or misrepresentations are made on this form.
___________________________________________________________________________________                                  _________________________
Signature of person completing this application                                                                       Date of Signature

___________________________________________________________________________________                                  _________________________  
Printed or typed name of person completing this application                                                           Telephone No.

The law requires the employer to post a copy of this completed application in a place where all workers can 
see it, and to submit the original to Unemployment Insurance Tax Office, 3025 W. Grand Blvd, Ste. 12-600, 
Detroit, MI 48202, not less than 20 days before the season will begin.

                                                UIA is an equal opportunity employer/program.  
         Auxiliary aids, services and other reasonable accommodations are available upon request to individuals with disabilities.