Employee Leasing Company Licensure And Registration Application Form
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1
2Vermont Department of Labor
VERMONT
Attn: Employee Leasing Program
P.O. Box 488
Department of Labor
Montpelier, VT 05601-0488
Employee Leasing Company Licensure & Registration Application
Registration information:
Company Name __________________________________________ Fed ID: ______________________
Mailing Address: _______________________________________________________________________
Street Address: _______________________________________________________________________
City _________________________
State __________________ Zip Code ______________________
Email Address: ________________________________________________________________________
Telephone #: _______________________________
Fax #: __________________________________
Address of Vermont office or Name and Address of Vermont Agent (If different from above.)
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
Email Address: _________________________________
Telephone #: _____________________________ Fax #: ______________________________
Contact person for Unemployment Insurance Matters
Name: _______________________________ Telephone #: ______________________________
Please list all individuals who are authorized to enter into contracts on behalf of the employee leasing
company. (Each individual indicated below is required to sign a "Authorizing Individual Affidavit", EL-5 form.)
Name:
Title:
__________________________________
____________________________________
__________________________________
____________________________________
__________________________________
____________________________________
__________________________________
____________________________________
__________________________________
____________________________________
Account information:
Please answer the following questions:
1. Do you have your own employees in the State of Vermont?
Yes (proceed to item 2)
No (proceed to Certification and Requirements section)
2. Are you registered as an employer for Unemployment Compensation purposes in Vermont?
Yes (proceed to item 3)
No (proceed to item 4)
3. Indicate your Vermont Department of Labor employer number here: ________________. Proceed to
Certification and Requirements section.
4. If you have not already been assigned a Vermont Department of Labor employer number, you must
complete and return an Employer Registration "Status Report", form C-1.
Page 1 of 2
EL-1 (11/05)
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