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Form Ls 550 - Application For A Certificate Of Eligibility To Employ Child Performers/verification Of Workers' Compensation/disability Insurance Coverage Form Page 2

Fees (check one)

Theater Capacity (1 to 499 Seats)

All Others

Initial Registration Fee-$200

Initial Registration Fee-$350

Renewal Fee -$200

Renewal Fee-$200

Declaration and Acknowledgement

Have you been found to be in violation of any sections of Part 186, of federal or state labor laws, or of other state or federal laws governing the

employment of child performers? No

Yes

If yes, describe the violations and their dispositions. Use back of form if necessary.

__________________________

_______________________________________________________________________________

Date of Violation

Nature of the Violation

The employer has read and agrees to abide by all laws, rules and regulations covering the employment of child performers including the

responsibilities listed in Part F, and understands that the failure to do so may result in the suspension or revocation of the certificate or in the denial of

its renewal.

I, the undersigned, am authorized to submit this application on behalf of the employer named in this application. By filing this application, I authorize

the Unemployment Insurance Division to release the records of the employer to the Division of Labor Standards and affirm that the information in

this application and all attachments is complete and accurate to the best of my knowledge.

___________________________________________________________

_______________________________________

Authorized Representative Signature

Date

___________________________________________________________

_______________________________________

Authorized Representative Name (Please Print)

Title

LS 550 (11-13)