Fill and Sign the Application for Oregon Worker Leasing License Oregon Form

Worker Leasing License Application (Initial application) Internal use only Received date: Approved date: An applicant must file this form to obtain an initial license. The Oregon Workers’ Compensation Division will request the $2,050 fee once it has approved your license. The license expires two years after issuance, unless a renewal application (Form 5364) is received and the license is renewed. [OAR 436-180-0140(3)] Email this application to WorkerLeasing.WCD@oregon.gov . If you have questions about this form, call 503-947-7544. Do not leave sections blank. Incomplete applications will not be accepted. APPLICANT 1. Applicant information Full legal name:       Assumed business name:       FEIN:       Yes No Does applicant also provide temporary workers under the same FEIN/entity in any state? Mailing address:       Physical address:       (If different from mailing address) 2. Contact information                   Licensing contact Phone Email                   Secondary contact Phone Email                   Client proof of coverage contact Phone Email 3. Supporting documentation (a) Provide signed releases for tax compliance verification:  Oregon Employment Department  Oregon Department of Revenue  Internal Revenue Service (b) Attach written procedures that demonstrate how the applicant will ensure its clients provide adequate training, supervision, and instruction to meet the requirements of ORS chapter 654. (c) Attach a list of all states where the applicant operates as a worker leasing company. For each, identify license, registration, or certification numbers, expiration dates, and disclose any that are not in good standing. (d) If no states are listed under (c) above, attach a description of applicant’s experience, training, or education that demonstrates competency in providing worker leasing services. Experience, training, or education listed for each controlling person on Page 3 will also be considered. 2466 440-2466 (7/18/DCBS/WCD/WEB) Page 1 of 4 4. Applicant business history If you answer yes to any question below, complete the attached DISCLOSURE ADDENDUM . (a) Yes No Has applicant ever been convicted of a crime involving the following:  Fraud, perjury, dishonesty, or deception  Theft, burglary, money laundering, or embezzlement  Forgery, counterfeiting, bribery, or extortion  Securities, investment, or insurance violations (b) Yes No Does applicant have a record of any civil or administrative action involving the following:  Fraud, perjury, dishonesty, or deception  Theft, burglary, money laundering, or embezzlement  Forgery, counterfeiting, bribery, or extortion  Securities, investment, or insurance violations (c) Yes No Has applicant ever been the subject of an adverse administrative, civil, or criminal action related to worker leasing activities in any state? (d) Yes No Does applicant have a record of financial issues or insolvency, including but not limited to:  Bankruptcies  Financial defaults  Liens (unreleased only) 5. Affidavit of applicant I,       , acting on behalf of       , as the applicant, first being duly sworn, say that, to the best of my knowledge, the applicant is qualified in all respects for the worker leasing company license applied for in the Worker Leasing License Application; that I have answered all of the questions in this application truthfully; that any and all supporting documents submitted with this application are true, correct, and valid; that there have been no material omissions of fact, which would have bearing on the division’s decision to grant the requested license; and this affidavit is provided by me in the regular course without fraud or misrepresentation. I hereby authorize all persons, institutions, organizations, schools, governmental agencies, employers, references, or any others set forth directly or by reference in this application, to release to the Workers’ Compensation Division, Department of Consumer and Business Services, State of Oregon, any files, records, or information of any type reasonably required for the division to properly evaluate the applicant’s qualifications to be licensed as a worker leasing company in Oregon. Under penalty of perjury, I declare that all information provided in this application and accompanying documents, or information I may yet provide to support this application, is true and correct and discloses all material facts regarding the applicant’s background and qualifications for licensing. I understand that furnishing false information or failing to disclose information regarding the applicant’s background and qualifications may be grounds for refusing to issue a license or to revoke a license issued.       Signature of authorized representative Date of signature Verification upon oath or affirmation NOTARY PUBLIC SEAL State of       County of       Signed and sworn to or affirmed before me on       , 20    . Notary Public My commission expires:       2466 440-2466 (7/18/DCBS/WCD/WEB) Page 2 of 4 CONTROLLING PERSON This section must be completed by each controlling person, as defined below: OAR 436-180-0005(4) (a) A person who holds an ownership interest greater than or equal to the lesser of: (A) The average ownership interest of all owners; or (B) 10 percent; (b) A person who is an officer or director of a corporation; a member or manager of a limited liability company; a partner of a partnership; or (c) An individual who has the power to direct or cause the direction of the management, policies, or operation of a worker leasing company. 6. Controlling person information Full legal name:                   (First) (Middle) (Last) Other names used:             Date of birth:       Current position:       Date started in position:       Phone:       Email:       Residential address:       Business address:       (If different from applicant address) 7. Controlling person experience Yes No Do you have experience in the worker leasing (PEO) industry in any state? If yes, please describe:       If no, please describe other experience, training, or education that demonstrates competency in providing worker leasing companies.       8. Controlling person disclosures If you answer yes to question (a) through (d) below, complete the attached DISCLOSURE ADDENDUM . (a) Yes No Have you ever been convicted of a crime involving the following:  Fraud, perjury, dishonesty, or deception  Theft, burglary, money laundering, or embezzlement  Forgery, counterfeiting, bribery, or extortion  Securities, investment, or insurance violations (b) Yes No Do you have a record of any civil or administrative action involving the following:  Fraud, perjury, dishonesty, or deception  Theft, burglary, money laundering, or embezzlement  Forgery, counterfeiting, bribery, or extortion  Securities, investment, or insurance violations (c) Yes No Have you ever been the subject of an adverse administrative, civil, or criminal action related to worker leasing activities in any state? (d) Yes No Do you have a record of financial issues or insolvency, including but not limited to:  Bankruptcies  Financial defaults  Liens (unreleased only) Controlling person initials 2466 440-2466 (7/18/DCBS/WCD/WEB) Page 3 of 4 VERIFICATION: Under penalties for false swearing/false affirmation, I declare that the controlling person information submitted fully discloses the information required under OAR 436-180-0140(3)(b). The information provided on Page 3 is complete and truthful, and there is no omission of material fact as it relates to my personal history, to the best of my knowledge. As it applies to my association with an Oregon licensed worker leasing company (PEO), I pledge to comply and cause those under my supervision to comply with the requirements of ORS 656 and OAR 436-180.       Signature of controlling person Date 2466 440-2466 (7/18/DCBS/WCD/WEB) Page 4 of 4