GENERAL INFORMATION Answer fully. Use separate page if necessary.
1. Have you, or any organization to which you belonged, ever had a license to operate an employment agency in this or any other state?
If yes, when, where and under what name?
2. Have you, or any organization to which you belonged, ever been refused a license to operate an employment agency in this or any other state?
If yes, when, where and why?
3. Have you, or any organization to which you belonged, ever had an employment agency license revoked in this or any other state?
If yes, when, where and under what name?
4. Are you employed, or do you presently administer, own or otherwise participate in another employment agency in this or any other state?
If yes, where and for how long? List the name and address of agency (s) and nature of relationship:
5. Have you ever been convicted of a felony in this or any other state?
6. Do you owe and delinquent taxes to the state of Indiana?
7. If presently employed in a private employment agency, are you under an employment contract with your present employer?
8. If under contract with another agency, will the actions and scope of the proposed agency be in violation of that contract?
If yes, explain:
9. Will the agency be operating as a franchise?
If yes, name the franchise:
10. If the agency name is a Doing Business As (D/B/A) name, state the true name:
11. Agency Federal ID Number:
CERTIFICATE I arm and state that the above information and statements are true, complete and correct to the best of my knowledge and belief.
Signature Title Date
Subscribed and sworn before me this day of 20
State of Indiana, County of
Notary Public
My commission expires
Please Note: In addition to completing the above application, the following requirements must be met:
A. Attach to this application, a current personal or business nancial statement.
B. A personal credit report from an accredited national credit reporting rm, paid for by the applicant, must be forwarded by the reporting rm and
directed to the attention of: P.O. Box 2305 Indianapolis, IN 46206-2305, State Department of Revenue, Indiana Government Center North.
C. Proof of a $1000.00 employment agency bond is required by law and must accompany this application.
D. e licensing fee of $150.00 must accompany this application.
E. Attach to this application the schedule of fees, charges and commissions you expect to charge for your services, together with a copy of the agency
contract. (All advertisements and statements, window signs, door signs, and all literature used, displayed or circulated by any such agency shall
contain the regularly licensed name of the agency).
F. A complete statement of the proposed agency’s refund policy must accompany this application. Please Note: Elaborate fully as this statement of
refund policy will be used as reference if and when a refund complaint is led against the proposed agency. It is in the best interests of the agency
and the general public if clients of the proposed agency are fully apprised of the conditions involving the refund.
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[SEAL]
