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.
Three-character agency code
Change to Existing Establishment
Inactivate Exisiting Establishment
5 character code. The code assigned by the agency to identify the establishment.
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)
3 character field.
Street Address (line 1)
30 character field. Actual mail delivery address
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.
2 character field. The state abbreviation.
9 character field. The location's zip code, the 4 character zip code suffix is optional.
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
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.
The phone number (including area code) of the person who competed the form.
Name of designated Table Administrator.
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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