Fillable STATE OF NEW HAMPSHIRE EMPLOYEE LEASING RENEWAL APPLICATION (State of New Hampshire)

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STATE OF NEW HAMPSHIRE EMPLOYEE LEASING RENEWAL APPLICATION (State of New Hampshire)

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U.S.A. forms for State of New Hampshire

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WC-EMPLSNG-Renewal Page1 of 3 Revised: 2/9/2016
STATE OF NEW HAMPSHIRE
DEPARTMENT OF LABOR
CONCORD, NH 03301
EMPLOYEE LEASING RENEWAL APPLICATION
Filing Fee: $100.00
Name of Applicant: ___________________________________ Date: _________________
Address:___________________________________________________________________
__________________________________________________________________________
Federal Identification Number: _________________________________________________
Affiliated Companies (if any):
Please list the name and business address of all principals, owners, shareholders, partners,
officers, managers or persons and entities who own 10% or more of the applicant:
Please provide a description of the business(es) operated by the principles, owners,
shareholders, partners, officers, managers or individuals exercising the power to control the
day to day operation or direction of the applicant during the five years immediately
preceding the date of application:
WC-EMPLSNG-Renewal Page2 of 3 Revised: 2/9/2016
Have you ever had your license suspended or limited in any other jurisdiction or not paid
employee wages or benefits or federal or state payroll taxes or unemployment compensation
contributions when due? No____Yes____ (If yes, please explain) __________________
With the exception of minor traffic violations, has any person who is a principal, owner,
shareholder, partner, officer, manager or individuals exercising the power to control the day
to day operation or direction of the applicant ever been convicted of any crime which has not
been annulled by a court? No____Yes____ (If yes, please explain)_____________________
Has any person who is a principal, owner, shareholder, partner, officer, manager or
individuals exercising the power to control the day to day operations or direction of the
applicant ever been declared bankrupt, or made an assignment for the benefit of creditors?
No ___ Yes___ (If yes, please explain) _______________________________________
Name of Contact Person: ____________________________________________________
Mailing Address of Contact: _________________________________________________
Telephone: _________________________ Fax: ______________________________
Email Address: ____________________________________________________________
WC-EMPLSNG-Renewal Page3 of 3 Revised: 2/9/2016
ANSWERS TO ALL QUESTIONS MUST BE ACCURATE AND COMPLETE.
INFORMATION OBTAINED THROUGH INVESTIGATION SHOWING
MISSTATEMENTS, INCLUDING ANY INCOMPLETE ANSWERS IS SUFFICIENT
CAUSE FOR REJECTION OF THIS APPLICATION AND MAY FORM THE BASIS
FOR A REVOCATION OR SUSPENSION OF ANY LICENSE ISSUED
HEREUNDER.
I ___________________________ , the duly authorized _________________ of the
applicant hereby certify that the above answers and all documentation submitted with this
application are complete and true to the best of my knowledge and belief. All statements
are made under penalty of perjury.
Name of Applicant
By: _____________________________________
Name of its duly authorized ______________________
State of
County of
On this _______ day of ____________ 20 , before me,
the undersigned officer, personally appeared __________________________________ ,
known to me (or satisfactorily proven) to be the person whose name is subscribed to the
within instrument and acknowledged that he executed the same for the purposes therein
contained.
In witness whereof I hereunto set my hand and official seal.
Notary of Public __________________________ My Commission expires: _____________
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STATE OF NEW HAMPSHIRE EMPLOYEE LEASING RENEWAL APPLICATION (State of New Hampshire)

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Completed 21 July 2020

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