Form Bls-700-334 - Business License Application Supplement For Employment Agency, Branch Office Or Listing Service

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State of Washington
Owner/business name
Business Licensing Service
PO Box 9034
UBI number
Olympia, WA 98507-9034
1-800-451-7985
Business License Application Supplement for
Employment Agency, Branch Office Or Listing Service
Please read the back of this form for complete application checklist.
A
General manager information
General manager name
Telephone number
(
)
Other names used
General manager license number If none, see below
Address Street or route, city, state, zip code
If this manager is not currently licensed in Washington, application for a General Manager License can be made
by marking this box and including an additional $150 General Manager License application fee. The person named
above will be scheduled for an examination. (See information on General Manager License on the reverse of this
form.)
Has the manager been employed as an Employment Agency General Manager within the past
year? .....................................................................................................................................................
Yes
No
If you answered "yes," list on the back of this form the name and address of each employment agency location
this person currently manages or will manage.
B
Sole proprietor/officers/partners/general manager information
Has any owner, officer, managing employee or holder of more than 20% interest in this business:
1. Been convicted of a crime, misdemeanor or felony in this state, any other state, any other
Yes
No
jurisdiction, or by the federal government within the past 10 years? .............................................
2. Had a criminal complaint, accusation, or information presently pending or currently under
indictment in this state, any other state, any other jurisdiction, or by the federal government? .....
Yes
No
3. Held a professional or occupational license, certification, or permit which was fined, suspended,
revoked, refused or denied in this state, any other state, any other jurisdiction, or by the
federal government? ......................................................................................................................
Yes
No
4. Had a civil court order, verdict, or judgement entered in any court of competent jurisdiction in
this state, any other state, any other jurisdiction, or by the federal government? ..........................
Yes
No
5. Been engaged in, interested in or employed by anyone engaged in the business of an
employment agency? ....................................................................................................................
Yes
No
If you answered "yes" to any of questions 1 through 4, explain on the back of this form. Include the name of the
person involved, charge(s), date of conviction, civil judgement or order, county jurisdiction, state and disposition of
charges.
Upon filing, this document and the application become a public record
subject to public disclosure provisions pursuant to RCW 42.56.
For assistance or to request this document in an alternate format, visit or call 1-800-451-7985. Teletype (TTY) users may call 360-705-6718.
BLS-700-334 (5/20/11) Page 1 of 2

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