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1. Petitioner Information Receipt (If the employer is an individual, complete Number 1; Organizations complete Number 2.) Use the mailing address of the petitioner. 1. Legal Name of Employer: a. Last Name (Family Name) b. First Name (Given Name) c. Full Middle Name 2. Company or Organization: Name of Company or Organization 3. Mailing Address: a. C/O: (In Care Of, if any) Class: c. Suite/Apt. Number b. Street Number and Name # of Workers: Job Code: Validity Dates: d. City e. State/Pro.

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