Fillable Form Sfn 58619-Peo License Application.xfm printable pdf download

Form Sfn 58619-Peo License Application.xfm

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COMPLETE, PRINT, SIGN, AND MAIL OR FAX (If paying with credit card, complete Credit Card Payment Authorization on page 4)

FOR OFFICE USE ONLY

ID/License Number:

PROFESSIONAL EMPLOYER

ORGANIZATION LICENSE APPLICATION

WO Number:

SECRETARY OF STATE

SFN 58619 (10-2012)

Filed:

By:

Expiration Date:

REQUIRED ATTACHMENTS:

LICENSE FEE: $1000

•

Surety Bond in the minimum amount of $100,000 (see instructions)

•

Copy of quarterly contribution and wage report filed with Job Service North Dakota

LICENSE PERIOD: 1 YEAR

SEE INSTRUCTIONS FOR FEES, FILING AND MAILING INFORMATION

TYPE OR PRINT LEGIBLY

For reference, see North Dakota Century Code, Chapter 43-55

"The undersigned natural person provides the following information on behalf of the applicant for a professional employer organization license:"

1. Name of professional employer organization:

2. Federal ID Number

3. Any other business names under which the professional employer organization intends to conduct business in North Dakota:

4. Business type and jurisdiction of origin: (check one)

(check partnership type)

Sole Proprietorship

Partnership organized in the state of

General Partnership

Limited Partnership

Corporation incorporated in the state of

Limited Liability Company organized in the state of

Limited Liability Partnership

Other - Define:

Limited Liability Limited Partnership

state of

5. Date on which professional employer organization was created in jurisdiction of origin: (month, day, and year)

6. Fiscal Year End

Complete address of principal office of the professional employer organization: (Street/RR, PO Box if applicable,

8. Telephone Number

city, state, ZIP +4)

Complete address(es) of each office the professional employer organization maintains in North Dakota: (Street/RR, PO Box if applicable, city, state,

ZIP+4)

10.

List the jurisdictions (states or countries) where the professional organization has operated in the preceding 5 years including the business name used

and any alternative names, previous names of predecessors, and, if known, successor business entities:

Year

Jurisdiction

Business Name

continued