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MARYLAND NEW HIRE REGISTRY REPORTING FORM
 

Send completed forms to:
Maryland New Hire Registry
PO Box 1316
Baltimore, MD 21203-1316
Fax (410) 281-6004 or toll-free fax 1(888) 657-3534

To ensure the highest level of accuracy, please print neatly in capital letters and avoid contact with the edges of the boxes. The following will serve as an example:

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EMPLOYER INFORMATION
Federal Employer Id Number (FEIN):
FEIN that appears on quarterly wage reports.

State Unemployment Insurance Number (MD Only SUIN):


If SUIN not issued yet, please write "APPLIEDFOR" in the above box. If Exempt, write "EXEMPT".

Employer Name:
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 (5digit):
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 (410 281-60000 or toll-free 1 (888) MDHIRES (634-4737. Report online at www.mdnewhire.com

to validate this form then click the "Submit" button.