UTAH NEW HIRE REGISTRY REPORTING FORM
Today’s Date (mm/dd/yyyy)
*
/
Month
/
Day
Year
Date
REQUIRED EMPLOYEE INFORMATION
Social Security Number
*
Name
*
First Name
Middle Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of hire/rehire (mm/dd/yyyy)
*
/
Month
/
Day
Year
Date
Employee’s birthdate (mm/dd/yyyy)
*
/
Month
/
Day
Year
Date
Submit
Should be Empty: