P.O. Box 2005, Oak Ridge, TN 37831

Online Enrollment Verification for CA

Please fill out this form completely before submitting.

Once the required notices have been posted at your worksite(s) and distributed to your employees, please complete and submit this form. Please note: This form is for our tracking purposes only and does not replace your own record of MPN notice distribution.

Employer Requirements:

This is to verify that the required MPN Notifications have been posted in a conspicuous location at the worksite(s) for convenient viewing by employees and the MPN Implementation Notice, in English, and also in Spanish to Spanish speaking employees, on the distribution date entered below, to each of the current employees located in California. The employer named above also confirms that it will distribute the MPN Implementation Notice to each new employee hired after the distribution dated entered below.