Employee Leasing Company Registration Form

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SAMPLE AFFIDAVIT
For Questions # 7 - If Applicable
PLEASE TRANSFER TO COMPANY LETTERHEAD
EMPLOYEE LEASING COMPANY REGISTRATION
I the undersigned, (Name of Individual),
(Title)
of
(Name of Company)
affirm the fact that our company has never had
Workers’ Compensation coverage canceled or non-renewed in the preceding
five years.
It is sworn and attested to that the above facts and statements are true and
accurate.
__________________________________________
Name\Title (Chief Executive Officer, Partner
or Sole Proprietor)
__________________________________________
Date
______________________________
Notary Public Signature\Stamp
______________________________
Date

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