Employee and Bank Information

Please fill out the following information. An * designates a required field.
First Name: *
Last Name: *
Title:
Bank: *
Email: *
Telephone:

Report Information

Please select the call reports you are responsible for filing with the DIF:
Would you like to view and/or print output reports online?

Username Information

In order to ensure proper security, please input your desired Username in the text box below. This will be your access into the DIF website. Your Username must be a minimum of 6 characters with no spaces (for example: fjones, cwalsh, JohnDoe). The Username is case sensitive.
Username: *
If you have any questions, please use the Contact Us page.