Employee Census Form

1. Client/Company:    ___________________________________   

    Date:    ____________

2. Address:    

    ________________________________________________________________________

3. Your Name:  _________________________

4. Phone Number: __________________    Industry:  ___________________      

    Product/Service:  _________________   

    

Employee	Check if Owner, Officer, Partner	Sex	Annual Base  Compensation	Birth Date Month / Year		Enter Codes: EE: Employee ES: Employee &  Spouse EC: Employee & Child ESC: Employee, Spouse &  # of Child
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