Free Employee Leasing Renewal Application Download

STATE OF NEW HAMPSHIRE DEPARTMENT OF LABOR CONCORD, NH 03301 EMPLOYEE LEASING RENEWAL APPLICATION Filing Fee: $100.00 Name of Applicant: ___________________________________ Date: _________________ Address:___________________________________________________________________ Federal Identification Number: _________________________________________________ Affiliated Companies (if any): Please list the name and business address of all principals, owners, shareholders, partners, Please provide a description of the business(es) operated by the principles, owners, shareholders, partners, officers, managers or individuals exercising the power to control the day to day operation or direction of the applicant during the five years immediately preceding the date of application: WC-EMPLSNG-Renewal Page1 of 3 Revised: 2/9/2016 Have you ever had your license suspended or limited in any other jurisdiction or not paid employee wages or benefits or federal or state payroll taxes or unemployment compensation OffOff contributions when due? No____Yes____ (If yes, please explain) __________________ With the exception of minor traffic violations, has any person who is a principal, owner, shareholder, partner, officer, manager or individuals exercising the power to control the day to day operation or direction of the applicant ever been convicted of any crime which has not been annulled by a court? No____Yes____ (If yes, please explain)_____________________ OffOff Has any person who is a principal, owner, shareholder, partner, officer, manager or individuals exercising the power to control the day to day operations or direction of the applicant ever been declared bankrupt, or made an assignment for the benefit of creditors? No ___ Yes___ (If yes, please explain) _______________________________________ OffOff Name of Contact Person: ____________________________________________________ Mailing Address of Contact: _________________________________________________ Telephone: _________________________ Fax: ______________________________ Email Address: ____________________________________________________________ WC-EMPLSNG-Renewal Page2 of 3 Revised: 2/9/2016 ANSWERS TO ALL QUESTIONS MUST BE ACCURATE AND COMPLETE. INFORMATION OBTAINED THROUGH INVESTIGATION SHOWING MISSTATEMENTS, INCLUDING ANY INCOMPLETE ANSWERS IS SUFFICIENT CAUSE FOR REJECTION OF THIS APPLICATION AND MAY FORM THE BASIS FOR A REVOCATION OR SUSPENSION OF ANY LICENSE ISSUED HEREUNDER. I ___________________________ , the duly authorized _________________ of the applicant hereby certify that the above answers and all documentation submitted with this application are complete and true to the best of my knowledge and belief. All statements are made under penalty of perjury. Name of Applicant By: _____________________________________ Name of its duly authorized ______________________ State of County of On this_______ day of ____________ 20 , before me, the undersigned officer, personally appeared __________________________________, known to me (or satisfactorily proven) to be the person whose name is subscribed to the within instrument and acknowledged that he executed the same for the purposes therein contained. In witness whereof I hereunto set my hand and official seal. Notary of Public __________________________My Commission expires: _____________ WC-EMPLSNG-Renewal Page3 of 3 Revised: 2/9/2016