Free License Application Instruction - Arizona


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THE INDUSTRIAL COMMISSION OF ARIZONA LABOR DEPARTMENT INSTRUCTIONS FOR COMPLETING AN EMPLOYMENT AGENCY LICENSE APPLICATION 1. Before completing the Application, you should review the Employment Agency Statutes and Rules particularly R205-303, 304 and 305 which prescribes the license application procedure. 2. All questions on the Application and Supplemental Application are necessary and should be answered completely and accurately. The Application(s) and other required items should be submitted to the Labor Department AS SOON AS they are completed. Upon submission of an Application, the Department will begin its investigation pursuant to R20-5-308. 3. All Applications for an employment agency license must be considered by the Employment Agency Advisory Council and approved by The Industrial Commission of Arizona before a license is issued. 4. Once your application and other required items are received, your application and other required items will be reviewed by the Department within fifteen (15) days. You will be notified whether or not the application and other required items are complete. Within 120 days after your application is deemed complete, the Employment Advisory Council will consider your application and the Commission will issue an order granting or denying the license. The Department will deem the application withdrawn if, after forty-five (45) days of being notified, the candidate fails to file a complete application. A candidate can request an extension of time to file a complete application by filing a written request with the Department before the Department deems the application withdrawn. 5. Either a surety bond in the amount of $5,000.00, executed on a form provided by this Department, or a cash Deposit of $1,000.00 must be submitted prior to the consideration of an Application by the Advisory Council. The surety bond must identify as principal the name of the candidate for a License as well as the corporate name and/or trade name under which business will be conducted. If a cash deposit of $1,000.00 is posted, this must be increased to $5,000.00 or replaced by a surety bond in that amount before the license is issued. 6. After submitting your Application, you may contact the Labor Department at (602) 542-4515 to determine who must take the test and to make an appointment for them to do so. All persons determined by the Commission to be involved in the management and supervision of the proposed agency and any of its branches or divisions, must pass a written examination. The test is given regularly, both in Phoenix and Tucson. The test is designed to demonstrate your knowledge of the Employment Agency Statutes and Rules, the State Civil Rights Act, Unemployment Insurance Laws and Workers'Compensation Laws. 7. A copy of all receipts, contracts and other forms related to fees to which an applicant may become a party must be submitted to this Department for review. 8. If the candidate for a license is an individual who proposes to do business as a sole proprietorship, the following are required: (1) The application must include the complete employment history of the applicant TOGETHER WITH NAMES AND COMPLETE STREET AND NUMBER ADDRESSES INCLUDING ZIP CODES of former employers to be contacted by this Department and education records and/or military discharge records. (2) A current notarized financial statement (form enclosed). (3) Proof of registration of trade name from the Secretary of State' Office. (Information regarding s this may be obtained by writing or visiting that office at 1700 W. Washington, Capital Tower, West Wing, 7th Floor, Phoenix Arizona 85007; or by calling 542-4285.)

continued:

(4) If any other person in addition to the candidate is to be involved in the management and supervision of the proposed agency or any of its branches or divisions, such person(s) must complete a Supplemental Application. 9. If the application is submitted to do business as a partnership, the following are required: (1) Completion of the Supplemental Application by ALL PARTNERS. (2) A copy of the Partnership Agreement which must also include an authorization for one of the parties to act on behalf of the partnership in the license application. (3) Items (1) through (4) indicated in No. 8 above as they relate to all partners. 10. If the application is submitted to do business as a corporation, the following are required: (1) The candidate must submit a certified resolution of the corporation authorizing the application for a license and naming the individual(s) authorized to act on behalf of the corporation. (2) A copy of the Articles of Incorporation filed with the Arizona Corporation Commission. (Information regarding incorporation may be obtained from the Corporation Commission' Incorporation Division, 1200 W. Washington, s Phoenix, AZ 85007. Telephone: 542-4146) (3) The application must include the complete employment history of the candidate TOGETHER WITH NAMES AND COMPLETE STREET AND NUMBER ADDRESSES INCLUDING ZIP CODES of former employers to be contacted by this Department and copies of education records and/or military discharge records. (4) A current notarized financial statement (see personal and business forms enclosed). (5) If any other person in addition to the candidate is to be involved in the management and supervision of the proposed agency or any of its branches or divisions, such person(s) must complete a Supplemental Application. 11. If the proposed business is a franchise, a copy of the franchise agreement must be submitted. 12. If the candidate for a license is purchasing an existing employment agency, a copy of the sale / purchase agreement must be submitted. (LICENSES ARE NOT TRANSFERABLE. A NEW LICENSE MUST BE ISSUED TO A CANDIDATE BEFORE HE/SHE MAY OPERATE THE BUSINESS). Employment Agency license fee will be payable, as stipulated in A.R.S. 23-528 upon ISSUANCE of the license.
Return the completed Supplemental Application to: STATE LABOR DEPARTMENT P. O. BOX 19070 PHOENIX, ARIZONA 85005 Labor Department Locations: 800 West Washington, Suite 403, Phoenix, Az 85007 2675 East Broadway, Tucson, Az 85716 Telephone No.: (602) 542-4515 FAX No.: (602) 542-8097

THE INDUSTRIAL COMMISSION COMPLIES WITH THE AMERICANS WITH DISABILITIES ACT OF 1990. IF YOU NEED ANY OF OUR DOCUMENTS IN ALTERNATIVE FORMAT, CONTACT THE LABOR DEPARTMENT AT (602) 542-4515.

THE INDUSTRIAL COMMISSION OF ARIZONA LABOR DEPARTMENT

Application for Employment Agency License All questions must be answered by the applicant for a License. 1. 2. 3. 4. 5. 6. 7. 8. Applicant' Name _____________________________________________________________________________ s What other names have you used? _______________________________________________________________ Birthplace ___________________________________Date of Birth _____________________________________ Applicant' Number & Street Home Address ________________________________________________________ s City_________________________ State _________________________________ Zip ______________________ How long at the above address? _____________________ Phone: ____________________________________ If less than five years, previous home address ______________________________________________________ City_________________________State__________________________________ Zip______________________ When did you establish residency in Arizona? _______________________________________________________ (Disclosure of the following information is voluntary. The information will be used to fulfill the requirements of R20-5-308 of the Rules and Regulations Governing Private Employment Agencies to investigate the management and ownership of a proposed agency.) Social Security Number ________________________________________________________________________ Driver' License Number __________________________________________ State ________________________ s College attended ________________________________________________ Date _________________________ City ________________________________________________ State ___________________________________ Military Branch _____________________ Dates _______________Type of Discharge ______________________

9. APPLICANT' EMPLOYMENT HISTORY: S
List all employment or business association in chronological order beginning with current employment. PLEASE INCLUDE COMPLETE NUMBER & STREET ADDRESSES, INCLUDING ZIP CODES, OF FORMER EMPLOYERS SO THAT THE DEPARTMENT MAY SEND REFERENCE REQUESTS. INCOMPLETE INFORMATION COULD DELAY YOUR APPLICATION. You may include any volunteer work that was of more than one year' duration. Use additional page if s necessary. Please check the last column if you DO NOT WISH THE EMPLOYER TO BE CONTACTED.

Employer & Complete Address 1.

Your Position

Dates of Employment

Reason for Termination

Do Not Contact

2.

3.

4.

5.

6.

7.

(Use Additional page, if necessary.) Page 1 of 4 10. PERSONAL REFERENCES: List the names and complete street and number addresses, including zip codes, of at least three other persons, NOT former employers, or relatives, preferably residents of Arizona who have known you for two years or more. 1. Name___________________________Relationship___________________________How long known________ Number & Street Address_____________________________________________________________________

City______________________State______________________________Zip Code_______________________ 2. Name __________________________ Relationship ___________________________ How long known _______ Number & Street Address _____________________________________________________________________ City ______________________ State ______________________________ Zip Code _____________________ Name __________________________ Relationship ___________________________ How long known _______ Number & Street Address______________________________________________________________________ City_______________________State_______________________________Zip Code______________________ Name __________________________ Relationship____________________________ How long known_______ Number & Street Address _____________________________________________________________________ City ______________________ State ______________________________ Zip Code _____________________

3.

4.

11. Have you ever been convicted of a felony or misdemeanor other than a minor traffic violation? _______________ If yes, give details including trial date and location, and sentence imposed by Courts: __________________________________________________________________________________________ __________________________________________________________________________________________ 12. Have you had a final judgment issued against you in a civil action on account of fraud, misrepresentation or deceit. If yes, give details:_____________________________________________________________________ __________________________________________________________________________________________ 13. Have you ever been licensed as an employment agent in the State of Arizona? ___________________________ If yes, what was the name of your agency and the dates you were licensed? _____________________________ __________________________________________________________________________________________ 14. Have you ever been licensed as an employment agent in another state? ________________________________ If yes, what was the name of your agency? _______________________________________________________ Dates licensed ____________________________________ State ____________________________________ 15. Were any complaints filed against the agency?_________________________________________If yes, give details on the date, nature and disposition of any adversely adjudicated complaints: __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ 16. Has your agency or any agency you have been involved with had the license suspended or revoked by this state or any other state?_____________________________________________________If yes, what was the name of the agency, the date, the state licensed in and the reason?____________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ 17. Have you ever been denied in the application of any employment agency by this or any other state? ___________ If yes, what was the name of the proposed agency, the date, the state where you applied and the reason denied? __________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ 18. List any other experience in the employment agency business (include name of agency, complete number & street address including city, state, zip code, and dates): ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ 19. What is the name and the trade name under which you propose to do business? ___________________________________________________________________________________________ ___________________________________________________________________________________________ Page 2 of 4

20. What is the proposed location of this business? __________________________________________________________________________________________ __________________________________________________________________________________________ 21. Will the agency have any branches or separate locations? ______________ Include all addresses: __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ 22. List any divisions or other names to be used in connection with the name or trade name:

__________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ 23. List any abbreviated name or trade name to be used. INITIALS CANNOT BE USED PER A.A.C. R20-5-326. __________________________________________________________________________________________ __________________________________________________________________________________________ 24. Will the proposed business be: a sole proprietorship_______________________________________________ a partnership_____________________________________________________ a corporation_____________________________________________________ a franchise_______________________________________________________ If a corporation, list the corporate officers, their titles and address: Name Title Complete Address

List the names of all persons and corporations having a financial interest in the proposed agency and explain their role and percentage of ownership:

25. Check the types of personnel the proposed agency will service. Professional Baby-sitters Technical Domestics Clerical Artists Skille Musicians d Semi-Skilled Models Unskilled Talent Nurses/LPN' s Other Teachers EXPLAIN " Other" : 26. Will the proposed agency charge fees? _______________________________ (a) Exclusively to applicants? (b) Exclusively to employers? (c) Both to applicants and employers? Page 3 of 4 27. Do you intend to comply with the provisions of A.R.S. 23-527: (a) By submitting a surety bond in the amount of $5,000.00 before the application is considered by the Advisory ________________________ or Council: (b) By submitting a $1,000.00 cash deposit before the application is considered by the Advisory Council and replacing this with a surety bond in the amount of $5,000.00 or an additional cash amount of $4,000.00 prior to the issuance of the

license? ____________________________________________________________________________________ 28. In addition to the applicant for the license, list the names of all partners and other individuals who will be involved in the management and supervision of the proposed agency or any of its branches or divisions?

NOTE: Such individuals must complete a Supplemental Application. 29. Do you have workers compensation insurance?______________________________________________________ If yes, please provide the following: Insurance Carrier' s Name:_______________________________________________________________________ Policy No.:___________________________________________________________________________________ Effective dates:___________________________________to___________________________________________ Insurance Agent' name, address and telephone number: s ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ If you do not have worker' compensation insurance, please explain why: s ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ 30. If granted a license, do you agree to perform faithfully all acts and duties to comply with the terms, conditions, provisions and requirements set forth in Arizona Revised Statutes 23-521 through 23-536, and with any and all pertinent Rules adopted by the Industrial Commission of Arizona? _____________________________________ ____________________________________________________________________________________________ 31. Do you hereby authorize the Labor Department to conduct the investigation of this application required by R20-5-308 of the Employment Agency Rules? _______________________________________________________ ____________________________________________________________________________________________ Note: It is a felony to knowingly file a false or forged instrument with a Public Office in this State (A.R.S. 39 -161). AFFIDAVIT: Under penalties of perjury, I declare and affirm that the statements made in the foregoing application, including any accompanying attachments are true, complete and correct.

Applicant' Signature s Date ________________________________________________________________________________________________ NOTARIZATION: Subscribed and sworn to before me this ____________________ day of _____________________________________ 19 ________________. My Commission expires on :

Notary Public Page 4 of 4

LABOR DEPARTMENT FINANCIAL INVESTIGATIVE AUTHORIZATION

TO WHOM IT MAY CONCERN: You are hereby authorized to give to the Labor Department of the Industrial Commission of Arizona, or any of its representatives, any and all information, facts and particulars, which may be requested regarding the amounts in any savings and / or checking accounts. A copy of this form shall have the same effect as the original.

Applicant' Signature s Date

_____________________________________________________________________________________ NOTARIZATION:

Subscribed and sworn to before me this

day of

19

My commission expires on:

Notary Public

LABOR DEPARTMENT

EMPLOYMENT HISTORY INVESTIGATIVE AUTHORIZATION

TO WHOM IT MAY CONCERN: You are hereby authorized to give to the Labor Department of the Industrial Commission of Arizona, or any of its representatives, any and all information, facts and particulars, which may be requested regarding my employment record with your company, agency, etc., and to permit any person appointed by the Director, State Labor Department, to examine all appropriate employment records, if necessary.

A copy of this form shall have the same effect as the original.

Date

Signature

NOTARIZATION:

Subscribed and sworn to before me this

day of

19

My Commission expires on:

Notary Public

THE INDUSTRIAL COMMISSION OF ARIZONA State Labor Department P. O. BOX 19070, PHOENIX, ARIZONA 85005 EMPLOYMENT AGENCY BOND No. Effective Date KNOW ALL MEN BY THESE PRESENTS:

That I (we) (Principal) (Corporate Name) (Trade Name) as Principal, and a corporation organized under the laws of the State of , as Surety are indebted to the People of the State of Arizona, in the penal sum of Five Thousand ($5,00.00.) Dollars, for which payment we bind ourselves and our legal representatives and successors, jointly and severally. The condition of the obligation is that the Principal has made application for a license to operate a private employment agency and is required by the terms of Arizona Revised Statutes 23-521, et seq., to furnish a bond on the terms and conditions as set forth in such statutes. If Principal and Principal' agents and employees faithfully conform to and abide by the provisions of Arizona Revised s Statutes 23-521 et seq., and Arizona Administrative Rules R20-5-301, et seq., together with all amendments or supplementary acts now or hereafter promulgated, and if Principal honestly and faithful performs all obligations and undertakings made pursuant to the provisions of such statutes in the conduct of the operation of a private employment agency by Principal and Principal' agents and employees, then this obligation shall be null and void: otherwise, it shall be in full force and effect. s The total aggregate liability of Surety heron shall be limited to the sum of Five Thousand (5,00.00) Dollars. This Bond shall be deemed continuous in form and shall remain in full force and effect unless terminated or canceled by the Surety as to subsequent liability by giving thirty (30) days written notice to the Industrial Commission of Arizona and the named Principal; provided that such cancellation shall not effect any liability incurred or accrued hereunder prior to the termination of the notice period. The State of Arizona, acting through the Industrial Commission, reserves the right to terminate this bond at any time by the giving of thirty (30) days prior written notice thereof to the Surety and named Principal at the last known address of each. In the event Principal or Surety, or either of them, is served with notice or summons of any action brought against Principal or Surety under this Bond, written notice of the receipt of such action or summons shall immediately be given to The Industrial Commission of Arizona, Labor Department. SIGNED, sealed and dated this ______________ day of ______________________________, 19___________ Principal____________________________________________ (Agency Name) By _________________________________________________ (Responsible Agent) Surety ______________________________________________ By _________________________________________________ (Attorney-in-fact) SUBSCRIBED AND SWORN to before me this _________ day of __________________________ 19________ ___________________________________________________ Notary Public My Commission expires_____________________________ NOTICE TO INSURER: PLEASE ADVISE THIS DEPARTMENT IN WRITING PRIOR TO BOND CANCELLATION SO THAT WE MAY CONDUCT THE INVESTIGATION REQUIRED BY THE ADMINISTRATIAVE RULES.

THE INDUSTRIAL COMMISSION OF ARIZONA LABOR DEPARTMENT

INSTRUCTIONS FOR COMPLETING AN EMPLOYMENT AGENCY LICENSE SUPPLEMENTAL APPLICATION (For Responsible Managing Agents) 1. Before completing the Supplemental Application you should review the Employment Agency Statutes and Rules particularly R20-5-303 and 304 which prescribes the application procedure. 2. All questions on the Supplemental Application are necessary and should be answered completely and accurately.

The application should be submitted to the Labor Department AS SOON AS it is completed. Upon submission of an application, the Department will begin its investigation pursuant to R4-13-308. The application must include the complete employment history of the applicant together with names and complete addresses (including zip codes) of former employers to be contacted by this Department and education records and/or military discharge records. 3. After submitting the Supplemental Application, you may contact the Labor Department (542-4515) to make an appointment for taking the written test. The test is given regularly, both in Phoenix and Tucson. The test is designed to demonstrate your knowledge of the Employment Agency Statutes and Rules, the Civil Rights Act, Unemployment Insurance Laws, and Worker' Compensation laws. s 4. Upon completion of the Department' investigation, you and the Licensee will be notified, in writing, of your s qualification to act as a responsible managing agent in accordance with the Rules and Regulations Governing Private Employment Agencies.

--------------------------------------------------------------------------------------------------------------------------------------------------------

Return the completed Supplemental Application to: STATE LABOR DEPARTMENT P. O. BOX 19070 PHOENIX, ARIZONA 85005 Labor Department Locations: 800 West Washington, Suite 403, Phoenix, AZ 85007 2675 East Broadway, Tucson, Az 85716 Telephone No.:(602) 542-4515 FAX No.: (602) 542-8097

THE INDUSTRIAL COMMISSION COMPLIES WITH THE AMERICANS WITH DISABILITIES ACT OF 1990. IF YOU NEED ANY OF OUR DOCUMENTS IN ALTERNATIVE FORMAT, CONTACT THE LABOR DEPARTMENT AT (602) 542-4515.

THE INDUSTRIAL COMMISSION OF ARIZONA LABOR DEPARTMENT

Supplemental Application (For Responsible Managing Agents) ALL questions on this Supplemental Application must be answered completely and accurately by those persons determined by the Commission to be involved in the management and supervision of the employment agency. 1. 2. 3. 4. 5. 6. Name What other names have you used? Agency Name Your position in the agency Birthplace Home Address

Date of birth

City State Zip Home Phone How long at the above address? If less than five years, previous home address City State Zip 9. When did you establish residency in Arizona ?_________________________________________________________ 10. (Disclosure of the following information is voluntary. The information will be used to fulfill the requirements of R205-308 of the Rules and Regulations Governing Private Employment Agencies to investigate the management and ownership of a proposed agency). Social Security Number _________________________________________________________________________ Driver' License Number_________________________________ State____________________________________ s College attended________________________________________________________________________________ City___________________________________________ State__________________________________________ Military Branch____________________ Dates_______________________ Type of Discharge__________________ 11. EMPLOYMENT HISTORY: List all employment or business association in chronological order beginning with current employment. PLEASE INCLUDE COMPLETE NUMBER & STREET ADDRESSES, INCLUDING ZIP CODES, OF FORMER EMPLOYERS SO THAT THE DEPARTMENT MAY SEND REFERENCE REQUESTS. INCOMPLETE INFORMATION COULD DELAY YOUR APPLICATION. You may include any volunteer work which was of more than one year' duration. s Use additional page if necessary. Please check the last column if you DO NOT WISH THE EMPLOYER TO BE CONTACTED. 7. 8.

Employer & Complete Address 1.

Your Position

Dates of Employment

Reason for Termination

Do Not Contact

2.

3.

4.

5.

(Use additional page if necessary)

Page 1 of 3 12. PERSONAL REFERENCES: List the names and complete street and number addresses, including zip codes, of at least three other persons, NOT former employers, or relatives, preferably residents of Arizona who have known you for two years or more. 1. Name___________________________Relationship___________________________How long known________ Number & Street Address_____________________________________________________________________ City______________________State______________________________Zip Code_______________________ Name __________________________ Relationship ___________________________ How long known _______ Number & Street Address _____________________________________________________________________ City ______________________ State ______________________________ Zip Code _____________________ Name __________________________ Relationship ___________________________ How long known _______ Number & Street Address______________________________________________________________________ City_______________________State_______________________________Zip Code______________________ Name __________________________ Relationship____________________________ How long known_______ Number & Street Address _____________________________________________________________________ City ______________________ State ______________________________ Zip Code _____________________

2.

3.

4.

13. Have you: (a) Ever been the subject of a voluntary or involuntary petition in bankruptcy?___________________ Date________________________________ (b) Ever been adjudicated bankrupt?_____________________Date__________________________ (c) Ever been an officer or a partner in any establishment subject to a voluntary or involuntary position in bankruptcy?________________________ (d) Ever been an officer or a partner in any establishment adjudicated bankrupt?________________ 14. Have you ever been convicted of a felony or misdemeanor other than a minor traffic violation? ______________ If yes, give details including trial date and location, and sentence imposed by Courts: __________________________________________________________________________________________ __________________________________________________________________________________________ 15. Have you had a final judgment issued against you in a civil action on account of fraud, misrepresentation or deceit. If yes, give details:_____________________________________________________________________ __________________________________________________________________________________________ 16. Have you ever been licensed as an employment agent in the State of Arizona? ___________________________ If yes, what was the name of your agency and the dates you were licensed? _____________________________ __________________________________________________________________________________________ 17. Have you ever been licensed as an employment agent in another state? ________________________________ If yes, what was the name of your agency? ____________________________________________________ Dates licensed ____________________________________ State ____________________________________ 18. Were any complaints filed against the agency?_________________________________________If yes, give details on the date, nature and disposition of any adversely adjudicated complaints: __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ 19. Has your agency or any agency you have been involved with had the license suspended or revoked by this state or any other state?_____________________________________________________If yes, what was the name of the agency, the date, the state licensed in and the reason?____________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ 20. Have you ever been denied in the application of any employment agency by this or any other state? ___________ If yes, what was the name of the proposed agency, the date, the state where you applied and the reason denied? ___________________________________________________________________________________________ ___________________________________________________________________________________________ 21. List any other experience in the employment agency business (include name of agency, complete number & street address including city, state, zip code, and dates): ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ Page 2 of 3 22. Do you hereby authorize the Labor Department to conduct the investigation of the above facts as required by R205-317 (G) of the Rules and Regulations Governing Private Employment Agencies?________________________ Note: It is a felony to knowingly file a false or forged instrument with a Public Office in this State (A.R.S. 39-161).

AFFIDAVIT: Under penalties of perjury, I declare and affirm that the statements made in the foregoing application, including any accompanying attachments are true, complete and correct.

________________________________________ Applicant' Signature s

________________________________________ Date

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------NOTARIZATION: Subscribed and sworn to before me this ____________ day of _________________________________, 19_____________

My commission expires on: ________________________ ___________________________________________________ Notary Public

Page 3 of 3
THE INDUSTRIAL COMMISSION OF ARIZONA - LABOR DEPARTMENT RENEWAL APPLICATION FOR EMPLOYMENT AGENCY LICENSE Answer ALL questions (if NONE, please state so)

1. Licensee' Name: _________________________________________ Position: ________________________________________ s Home Address:________________________________________________________ Tel. No.: ___________________________ 2. Agency name. If a corporation, indicate corporate name and trade name:_____________________________________________ ____________________________________________________________________ Tel. No.: ___________________________ Agency' Address: _______________________________________________________________________________________ s Current Legal Status: Sole Proprietorship _________ Partnership__________ Corporation__________ Responsible Managing Agent (if different from above): ____________________________________________________________ Home address: ______________________________________________________________ Tel. No.______________________ If there has been a change in partners or corporate officers since your last license renewal, please list NEW PARTNERS / CORPORATE OFFICERS: ______________________________________________________________________ _______________________________________________________________________________________________________ Type of license: General_________ Career Counseling_________ Talent__________ Sitter_____________ APF_________ EPF__________ Both_____________ List the addresses of ALL BRANCHES COVERED BY THIS LICENSE: _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ List ALL DIVISIONS operated by this agency:___________________________________________________________________

3. 4.

5.

6.

7.

8.

_______________________________________________________________________________________________________ 9. List any abbreviation of agency name which licensee uses per A.A.C. R20-5-326. (INITIALS CANNOT BE USED.): _______________________________________________________________________________________________________ Do you operate a business other than this agency?_____________ If yes, give location and describe:_____________________ ______________________________________________________________________________________________________ Average number of counselors employed during preceding licensed year including yourself and manager:_______ No. of other staff:_________ Have there been any changes in receipts, contracts, schedule of fees or other forms related to fees used by your agency since your last application?:__________ If yes, please attach a copy of new forms. Has the agency had any complaints filed against it through this Department in the preceding licensed year?________________ If yes, list complaint number, complainant' name and outcome.___________________________________________________ s ______________________________________________________________________________________________________ Does your business have worker' compensation insurance as required by A.R.S. 23-901?___________. If no, please explain s why:___________________________________________________________________________________________________ Insurance Carrier' Name: ________________________________________________________________________________ s Policy No.:_______________________________________ Effective dates:__________________________________________ Insurance Agent' name, address and phone number:___________________________________________________________ s ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ We ( I ), the undersigned, being first duly sworn, according to law, depose and say that the statements and answers made in this application are true. FURTHER, WE ( I ) will not dispose of any interest in this Agency or change its location until approval has first been obtained from the State Labor Department of The Industrial Commission of Arizona. __________________________________________________ Applicant' Signature s ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------SWORN TO BEFORE ME AND SUBSCRIBED in my presence this __________________ day of ________________________, 19_________________. ________________________________________________ Notary Public My Commission expires: _________________________________________ Dated_________________________________________

10.

11.

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14.

LABOR DEPARTMENT
BUSINESS FINANCIAL STATEMENT Partnership Applicant Corporation Sole Propriertorship

_______________________________________________________________________________________________________ (Name of Partnership or Corporation & Any Trade Names(s)

Business Address

___________________________________________________________________________________________________ (Number & Street) ___________________________________________________________________________________________________ (City) (State) (Zip) Have you, or any officer, director, partner or active manager thereof, filed bankruptcy within the last ten years? Yes _________ No__________ If yes, furnish complete details and dates:___________________________________________________________________________________ Have you, or any officer, director, partner or active manager been convicted of misappropriating funds? Yes_____________ No_______________ If yes, give details and dates:_____________________________________________________________________________________________ Statement of applicant' assets and liabilities as of s ASSETS Cash Amount Accounts Payable Stocks/Bonds* Notes Receivable* Real Estate, Investment* 19

Furniture & Fixtures Other Assets TOTAL ASSETS *Describe on separate sheet to be attached hereto. LIABILITES Accounts Payable Taxes Due & Accrued Notes Payable to Bank Notes Payable (Other) Mortgage on Real Estate Other Liabilities*

TOTAL LIABILITIES Capital Stock (Paid In) Surplus or Net Worth TOTAL *Describe on separate sheet to be attached hereto. NOTE: It is a felony to knowingly file a false or forged instrument with a Public Office in this State (A.R.S. 39-161). AFFIDAVIT: Under penalties of perjury, I declare and affirm that the statements made in the foregoing financial statement, including any accompanying attachments are true, complete and correct. __________________________________ (Date) _______________________________________________________________ (Signature) (Title)

Home Address: _________________________________________________________________________________________________ (Number & Street) (City) (State) (Zip) ----------------------------------------------------------------------------------------------------------------------------------------------------------------------NOTARIZATION: Subscribed and sworn before me this __________________day of _______________________, 19_____________ *seal* My commission expires on __________________________________________________Notary Public