Establishment Change Form
You will NOT receive a confirmation saying MMB has received your form; the Security Administrator will contact you when the addition or change has been made.
Agency Name *
Your answer
Agency Code *
Three-character agency code
Your answer
Establishment ID
5 character code. The code assigned by the agency to identify the establishment.
Your answer
Effective Date
format: MM/DD/YY
Your answer
Establishment Name
30 character maximum field. The name of the establishment that should appear on SEMA4 pages and reports. This description should be unique. (Start name with agency acronym. For example DNR, DOT, MMB)
Your answer
3 character field.
Your answer
Street Address (line 1)
30 character field. Actual mail delivery address
Your answer
Street Addess (line 2)
For dual addresses place the intended mail delivery address on this line and the less important address information on line 1.
Your answer
Your answer
2 character field. The state abbreviation.
Your answer
9 character field. The location's zip code, the 4 character zip code suffix is optional.
Your answer
SIC Code
4 character Standard Industrial Code. To find a valid list of SIC codes, go to the SEMA4 Home page and click through the following pages: Set Up HRMS - Product Related - Workforce Monitoring - Health and Safety - SIC Code Table
Your answer
Does this establishment employ apprentices?
Name of Person Completing This Form *
If someone other than the Table Administrator is completing this form, they should record their name in this field.
Your answer
Email *
Your answer
Phone *
The phone number (including area code) of the person who competed the form.
Your answer
Table Administrator *
Name of designated Table Administrator.
Your answer
Electronic Signature Mandatory *
Checking this box means the Table Administrator completed this form or the Table Administrator has knowledge of and has apporved the completed form. This signature is mandatory. The form will not be processed without the electronic signature box checked.
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