Form Duplicate Cert.
Rev. 11/11
STATE OF NEW JERSEY
Division of Purchase & Property, Contract Compliance Audit Unit
EEO Monitoring Program
DUPLICATE CERTIFICATE OF EMPLOYEE INFORMATION REPORT REQUEST
IMPORTANT- FAILURE TO PROPERLY COMPLETE THE ENTIRE FORM AND SUBMIT THE REQUIRED $75.00 FEE (Non-Refundable)
MAY DELAY ISSUANCE OF YOUR DUPLICATE CERTIFICATE OF EMPLOYEE INFORMATION REPORT.
SECTION A - COMPANY IDENTIFICATION
1. FID. NO. OR SOCIAL SECURITY
3. COMPANY NAME
4. STREET
CITY
COUNTY
STATE
ZIP CODE
ISSUE DATE
EXPIRATION DATE
2. ASSIGNED CERTIFICATION NUMBER
5. REASON FOR REQUEST OF DUPLICATE CERTIFICATE
1. Lost Certificate 2. Damaged 3. Other (Specify)
SECTION C - OFFICIAL USE ONLY
RECEIVED DATE:
DIVISION OF REVENUE DLN # :
SECTION B - SIGNATURE AND IDENTIFICATION
6. NAME OF PERSON COMPLETING FORM (Print or Type)
SIGNATURE
TITLE
DATE
MO DAY YEAR
7. ADDRESS NO. & STREET
CITY
COUNTY
STATE
ZIP CODE PHONE (AREA CODE, NO.,EXTENSION)
- -
I certify that the information on this Form is true and correct.
ITEM 1 - Enter the Federal Identification Number assigned by the Internal Revenue Service, or if a Federal Employer Identification
Number has been applied for, or if your business is such that you have not or will not receive a Federal Employer Identification
Number, enter the Social Security Number of the owner or of one partner, in the case of a partnership.
ITEM 2 - Enter the Certificate Number that was assigned to your company along with the Issue Date and Expiration Date (If
available).
ITEM 3 - Enter the name by which the company is identified.
ITEM 4 - Enter the physical location of the company. Include City, County, State and Zip Code.
ITEM 5 - Enter the reason for requesting a Duplicate Certificate of Employee Information Report.
ITEM 6 - Print or type the name of the person completing the form. Include the signature, title and date.
ITEM 7 - Enter the physical location where the form is being completed. Include City, State, Zip Code and Phone Number.
RETAIN A COPY OF THIS REQUEST FOR THE VENDOR'S OWN FILES AND FORWARD ONE COPY WITH A CHECK IN THE AMOUNT OF
$75.00 (Non-Refundable Fee) PAYABLE TO "THE TREASURER, STATE OF NEW JERSEY" TO:
NJ Department of the Treasury
Division of Purchase & Property
Contract Compliance Audit Unit
EEO Monitoring Program
PO Box 206
Trenton, New Jersey 08625-0206 Telephone No. (609) 292-5473
PLEASE ALLOW 15 BUSINESS DAYS FOR PROCESSING THE DUPLICATE CERTFICATE
INSTRUCTIONS FOR COMPLETING DUPLICATE CERTIFICATE REQUEST
DEPARTMENT OF THE TREASURY
