EMPLOYER REGISTRATION RETURN TO WORK DIVISION SFN 53215 (05/2008) 1600 EAST CENTURY AVENUE, SUITE 1 PO BOX 5585 BISMARCK ND 58506-5585 TELEPHONE 1-800-777-5033 Toll Free Fax 1-888-786-8695 TTY (hearing impaired) 1-800-366-6888 Fraud and Safety Hotline 1-800-243-3331 www.WorkforceSafety.com EMPLOYER INFORMATION Company Name WSI Account Number Street Address City, State, and Zip Code Phone Number Contact Person JOB INFORMATION Job Title Wage Address of Job Site (if different than listed above) City, State, and Zip Code (if different than listed above) Required Education (list degrees or formal training) Required Licenses/Certificates Necessary Experience Hours Per Week Check one: Full-time Part-time Temporary Closing Date Job Description (please be specific to include all physical demands) To Apply American LegalNet, Inc. www.FormsWorkFlow.com