Form Ba - Business Agent Registration

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Note: Please type or print legibly with black ink.
State of Kansas/Application
Form
Business Agent Registration
BA
Applicant’s Name ___________________________________________________________________
Street Address ______________________________________________________________________
City, State, Zip Code _________________________________________________________________
Applicant desires to operate in Kansas
as a business agent for:
Organization ________________________________
__________________________________________
Address ___________________________________
__________________________________________
Do not write in this space.
Daytime Phone No. __________________________
I am applying for a registration certificate as a business agent of a labor or employee organization. In support of
my application, I make the following statements:
1) I am a citizen of the United States.
2) A registration fee of $12.50 is included with my application.
3) I have been a resident of Kansas for _________________ (if not a resident, state none).
4) My registration certificate can be issued for the calendar year in which it is received or for the fiscal
year of the organization expiring on the last day of the fiscal year, but neither can be for more than 12 months.
The certificate will expire (indicate one):
a) December 31, ______ or b) ___________, _______ (last day of fiscal year)
Year
Year
Signature of applicant
Statement of President and Secretary of Organization:
To the Secretary of State, State of Kansas:
Applicant name ________________________________________________________________,
whose home address is __________________________________________________________,
is duly authorized by (name of organization) _______________________________________
to act as its business agent as such term is defined in sections of K.S.A. 44-802 and 75-4322,
as amended.
President
President
(signature)
(printed or typed)
Secretary
(printed or typed)
Secretary
(signature)
Mail application to:
Ron Thornburgh
Secretary of State
First Floor, Memorial Hall
120 S.W. 10th Ave.,
Topeka, KS 66612-1594
(785) 296-4564
Rev. 12/99 kp

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