Employer Census
General Information
Employer Name
Address
City
State
CA / Home office in CA Only
Zip
County
Contact Name
Telephone
Contact me by: Phone   Email
Best time
 Morning  Afternoon  Evening
Email
Total Employees

   
Census (1-15 Employees): For groups over 15 you may submit the above information and a
representative will contact you, or you may submit employee information in batches of 15.
 
Employee Name
Date of Birth
  
Male
Female
Spouse
   Dep  
1
 
 
Yes
No
         
2
 
 
Yes
No
         
3
 
 
Yes
No
         
4
 
 
Yes
No
         
5
 
 
Yes
No
         
6
 
 
Yes
No
         
7
 
 
Yes
No
         
8
 
 
Yes
No
         
9
 
 
Yes
No
         
10
 
 
Yes
No
         
11
 
 
Yes
No
         
12
 
 
Yes
No
         
13
 
 
Yes
No
         
14
 
 
Yes
No
         
15
 
 
Yes
No
         
 


 
 

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