*indicates mandatory

Employing Unit Type*:	-Select- Industrial/Training Film(s) OnlyStudent Representative Film(s)Non-profit OrganizationMovie ProductionsCommercial Advertising Productions OnlyLive ProductionOther
Other employer type*:
Employing Unit Name*:
Doing Business As:
Select type(s) of business*:	-Select- Production CompanyManagement CompanyCasting AgencyAdvertising AgencyOther
Other Type of Business*:
Georgia Mailing Address
Address Line 1*:
Address Line 2:
City*:
State*:	GA
Zip Code*:	-
Georgia Location Address
Is Location Address same as Georgia Mailing Address?*	Yes   No
Address Line 1*:
Address Line 2:
City*:
State*:	-Select- AlaskaAlabamaArkansasArizonaCaliforniaColoradoConnecticutDistrict of ColumbiaDelawareFloridaGeorgiaHawaiiIowaIdahoIllinoisIndianaKansasKentuckyLouisianaMassachusettsMarylandMaineMichiganMinnesotaMissouriMississippiMontanaNorth CarolinaNorth DakotaNebraskaNew HampshireNew JerseyNew MexicoNevadaNew YorkOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVirginiaVirgin IslandsVermontWashingtonWisconsinWest VirginiaWyoming
Zip Code*:	-
Corporate Mailing Address
Is Corporate Mailing Address same as Georgia Mailing Address?*	Yes   No
Address Line 1*:
Address Line 2:
Country*:	-Select- UNITED STATESCANADAAFGHANISTANALBANIAALGERIAAMERICAN SAMOAANDORRAANGOLAANGUILLAANTIGUA AND BARBUDAARGENTINAARMENIAARUBAAUSTRALIAAUSTRIAAZERBAIJANBAHAMASBAHRAINBANGLADESHBARBADOSBELARUSBELGIUMBELIZEBENINBERMUDABHUTANBOLIVIABONAIREBOSNIA-HERZEGOVINABOTSWANABOUVET ISLANDBRAZILBRUNEIBULGARIABURKINA FASOBURUNDICAMBODIACAMEROONCAPE VERDECAYMAN ISLANDSCENTRAL AFRICAN REPUBLICCHADCHILECHINACHRISTMAS ISLANDCOCOS (KEELING) ISLANDSCOLOMBIACOMOROSCONGO, DEMOCRATIC REPUBLIC OF THECONGO, REPUBLIC OFCOOK ISLANDSCOSTA RICACROATIACUBACURACAOCYPRUSCZECH REPUBLICDENMARKDJIBOUTIDOMINICADOMINICAN REPUBLICECUADOREGYPTEL SALVADOREQUATORIAL GUINEAERITREAESTONIAETHIOPIAFALKLAND ISLANDSFAROE ISLANDSFIJIFINLANDFRANCEFRENCH GUIANAGABONGAMBIAGEORGIAGERMANYGHANAGIBRALTARGREECEGREENLANDGRENADAGUADELOUPE - FRENCHGUATEMALAGUINEAGUINEA BISSAUGUYANAHAITIHOLY SEEHONDURASHONG KONGHUNGARYICELANDINDIAINDONESIAIRANIRAQIRELANDISRAELITALYIVORY COAST (COTE D`IVOIRE)JAMAICAJAPANJORDANKAZAKHSTANKENYAKIRIBATIKOSOVOKUWAITKYRGYZSTANLAOSLATVIALEBANONLESOTHOLIBERIALIBYALIECHTENSTEINLITHUANIALUXEMBOURGMACAUMACEDONIAMADAGASCARMALAWIMALAYSIAMALDIVESMALIMALTAMARTINIQUE - FRENCHMAURITANIAMAURITIUSMAYOTTEMEXICOMICRONESIAMOLDOVAMONACOMONGOLIAMONTENEGROMONTSERRATMOROCCOMOZAMBIQUEMYANMARNAMIBIANAURUNEPALNETHERLANDSNETHERLANDS ANTILLESNEW CALEDONIA - FRENCHNEW ZEALANDNICARAGUANIGERNIGERIANIUENORFOLK ISLANDNORTH KOREANORWAYOMANPAKISTANPANAMAPAPUA NEW GUINEAPARAGUAYPERUPHILIPPINESPITCAIRN ISLANDPOLANDPOLYNESIA - FRENCHPORTUGALQATARREUNIONROMANIARUSSIARWANDASAINT HELENASAINT KITTS AND NEVISSAINT LUCIASAINT PIERRE AND MIQUELONSAINT VINCENT AND GRENADINESSAMOASAN MARINOSAO TOME AND PRINCIPESAUDI ARABIASENEGALSERBIASEYCHELLESSIERRA LEONESINGAPORESINT MAARTENSLOVAKIASLOVENIASOLOMON ISLANDSSOMALIASOUTH AFRICASOUTH GEORGIA AND SOUTH SANDWICH ISLANDSSOUTH KOREASOUTH SUDANSOUTH SUDANSPAINSRI LANKASUDANSURINAMESVALBARD AND JAN MAYEN ISLANDSSWAZILANDSWEDENSWITZERLANDSYRIATAIWANTAJIKISTANTANZANIATHAILANDTIMOR-LESTE (EAST TIMOR)TOGOTOKELAUTONGATRINIDAD AND TOBAGOTUNISIATURKEYTURKMENISTANTURKS AND CAICOS ISLANDSTUVALUUGANDAUKRAINEUNITED ARAB EMIRATESUNITED KINGDOMURUGUAYUZBEKISTANVANUATUVENEZUELAVIETNAMWALLIS AND FUTUNA ISLANDSYEMENZAMBIAZIMBABWE
City*:
State*:	-Select- AlaskaAlabamaArkansasArizonaCaliforniaColoradoConnecticutDistrict of ColumbiaDelawareFloridaGeorgiaHawaiiIowaIdahoIllinoisIndianaKansasKentuckyLouisianaMassachusettsMarylandMaineMichiganMinnesotaMissouriMississippiMontanaNorth CarolinaNorth DakotaNebraskaNew HampshireNew JerseyNew MexicoNevadaNew YorkOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVirginiaVirgin IslandsVermontWashingtonWisconsinWest VirginiaWyoming
Zip Code*:	-
Province*:
Postal Code*:
Employing Unit Information
Phone Number*:
Fax Number:
Email Address*:
Student Representative*: (Select 'Yes' if you are a student working on a film for school credit purposes. Select 'No' if you are an Employing Unit hiring minors in entertainment)	Yes  No
Last 5 of SSN*:
School Name*:
GDOL State Employer Identification Number:	(Online Tax Registration Service for Employers)
Federal ID Number (FEIN)*:
NAICS Code*:	-Select- Theater Companies and Dinner TheatersDance CompaniesMusical Groups and ArtistsOther Performing Arts CompaniesPromoters of Performing Arts, Sports, and Similar Events with FacilitiesPromoters of Performing Arts, Sports, and Similar Events without FacilitiesAgents and Managers for Artists, Athletes, Entertainers, and Other Public FiguresIndependent Artists, Writers, and Performers
Worker's Compensation Policy Number
Select type(s) of work to be performed*:	-Select- ModelExtraActorFilmRadioBroadcastingReality SeriesPhotographyLive ProductionMusicalOther
Other type of work to be performed*:
Employing Unit Representative Information
Employing Unit Representative First Name:*:	-Select- Mr.Mrs.Ms.
Employing Unit Representative Middle Initial:
Employing Unit Representative Last Name:*:
Employing Unit Representative Suffix:	-Select- Jr.Sr.IIIIIIEsq.
Employing Unit Representative Title*:
Employing Unit Representative Phone Number*:
Employing Unit Representative Fax Number:
Willing to accept text messages?*	Yes   No
Employing Unit Representative Cell Phone Number*:
Employing Unit Representative Email Address*: (Please note the email address provided will also be used as your user id during login)
Confirm Email Address*:
Acknowledgements: Specific rules regarding the employment of Minors in Entertainment, such as definitions, age, hours of participation, and educational and other requirements can be found in the GDOL Rules - Chapter 300-7-1 - Child Labor - Minors in Entertainment.    I, the undersigned, as evidenced by my electronic signature, hereby attest that I am of lawful age; that I am the applicant or authorized signer for the applicant; that the information provided herein above, to my knowledge is true and correct; that I have reviewed, the Georgia Department of Labor's Rules 300-7-1.01 et seq and Georgia law as set forth in O.C.G.A. §§ 39-2-18, 39-2-19 and 39-2-20 concerning Minors in Entertainment. I acknowledge and understand that the filing of false information may make me subject to the penalties set forth O.C.G.A. § 16-10-20.
Click to Acknowledge. Electronic Signature*:

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