Employee List Form printable pdf download

Employee List Form

School:___________________________________________________________________________________ Date:__________________________

Attachment Q

EMPLOYEE LIST

Pursuant to G.L. c. 62C, § 47A, the Division of Professional Licensure (DPL) is required to obtain the social security number for each employee

and forward it to the Department of Revenue (DOR). The DOR will ascertain whether staff is in compliance with the tax laws of the

Commonwealth. In addition, effective 8/1/12, pursuant to Chapter 106 of the Acts of 2012, DPL may have access through the Department of

Criminal Justice Information Services to data about convictions and pending criminal cases of all school principals, owners, directors, officers, and

members of the business entity, as appropriate for the organizational ownership of the school.

Initial License Applicant: Effective 8/1/12, all staff must submit a resume and completed CORI Notification Acknowledgement and Employee

Information Form.

Renewal License Applicant: Staff is subject to CORI at each renewal.

List all staff employed by the school, except instructors and sales representatives (listed on Attachments P and R, respectively). If the school has

branches, please organize this list by branch or submit one list per branch.

Name of Staff Person

Social Security #

Date of Birth

Position Title

CORI Form and Resume

Attached

Updated 2/4/2016

Employee List Form