Fillable State Of New Jersey Instructions For Completing The (Town of Secaucus, New Jersey)

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State Of New Jersey Instructions For Completing The (Town of Secaucus, New Jersey)

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State of New Jersey
Department of Labor and Workforce Development
Division of Wage and Hour Compliance
PO Box 389
Trenton, New Jersey 08625-0389
Instructions for Completing the Application for Public Works Contractor Registration
The Public Works Contractor Registration Act (N.J.S.A. 34:11-56.48, et seq.) requires all contractors,
subcontractors, or lower tier subcontractors (including subcontractors listed in bid proposals) who bid on or engage
in the performance of any public work to register with the Department of Labor and Workforce Development. The
Contractor Registration Certificate is issued to both the company (the business name listed in question #1) and the
company’s responsible owners/officers (the individuals listed in question #9).
All applications must be accompanied by a check or money order made payable to the Commissioner of Labor and
Workforce Development. We do not accept cash. Mail the application, check, and any other required documentation
or forms to the Division of Wage and Hour Compliance (mailing address is on the back of this form).
Type of Application and Certificate Number:
Check appropriate box for new or renewal registration. If renewal, indicate current certificate number.
New Application or One-Year Renewal – Fee is $300 and non-refundable.
Two-Year Renewal – Fee is $500 and non-refundable. A two-year renewal is available only to
employers who have been continuously registered for the past two consecutive years.
Questions 1 – 15: Answer all questions. Failure to provide requested information will cause a delay in processing
the application. If the requested information is not subsequently provided, the application may be denied.
1. Business Name - Type or print legibly the name of business used to contract/subcontract public works
projects. This is the business name that will appear on the certificate of registration.
If more than one business entity name is party to contracts, separate registrations are required.
2. Legal / Corporate Name – If different than item #1. If the business entity is a sole proprietorship or
partnership, enter name of owner or partners.
3. Street Address – Enter the business’s street address, city, state, ZIP code, and county. Do not use a PO
Box.
4. Mailing Address - If different than item #3. This is the address to which notices and the public works
contractor registration certificate will be mailed.
5. Telephone Number, Fax Number, Email, and Website
6. FEIN (Federal Employer Identification Number) – This is the business’s taxpayer identification number.
Any business that has employees and/or pays any kind of taxes must have a FEIN.
If business entity is a sole proprietorship with no employees and does not have an assigned FEIN from the
IRS, enter the owner’s SSN. Please indicate on application that you are providing a SSN.
7a. Type of Business – Check off the type of ownership. Enter the state of incorporation. Enter the date the
business was started or incorporated. Enter the NJ Business/Corp. No. if known. Enter the total number of
employees.
MW-20 (R-9-17-15)
7b. Registered Agent - Out-of-state applicants must appoint a registered agent in New Jersey who will accept
legal service in New Jersey.
Permit to Maintain Payroll Records Outside of New Jersey - If you are a new out-of-state applicant
and plan to keep your payroll/business records outside of New Jersey, you must complete a Request for
Permission to Maintain Payroll Records Outside of NJ (form MW-42). To get this form, go to
www.nj.gov/labor and click on Wage & Hour then Registration & Permits, or call (609) 292-9464.
8. Workers’ Compensation Coverage – All businesses that operate in New Jersey must have workers’
compensation insurance. The expiration date must be at least 30 calendar days from date of application.
Sole proprietors, partnerships and LLCs with no workers’ compensation coverage and no employees may
complete the certified statement in item #8.
9. Responsible Owners/Officers – List each individual with a financial interest in the business – except that
if the business is a publicly traded corporation – the corporation’s officers.
If the applicant business is owned by another business entity, you must still list the responsible individuals
for the applicant business. If the individual owners, partners, managing members, members or corporate
officers are not listed, the processing of your application will be delayed and considered incomplete.
Questions 10 – 15: Read each question carefully and give complete and accurate responses. Add additional sheets
and documentation if necessary. Be sure to check Yes or No; do not use “N/A” or leave blank.
Question 10: Be sure to disclose any association with other firms. Use the definition of “interest” as defined
below to guide your response.
Pursuant to N.J.A.C. 12:60-7.2, “interest” is defined as follows:
"Interest" means an interest in the entity bidding or performing work on the public works project, whether
as an owner, partner, officer, manager, employee, agent, consultant or representative. The term also includes, but
is not limited to, all instances where the debarred contractor or subcontractor receives payments, whether cash or
any other form of compensation, from any entity bidding or performing work on the public works project, or
enters into any contracts or agreements with the entity bidding or performing work on the public works project for
services performed, or to be performed, for contracts that have been or will be assigned or sublet, or for vehicles,
tools, equipment or supplies that have been or will be sold, rented or leased during the period from the initiation of
the debarment proceedings until the end of the term of the debarment period. "Interest," however, does not include
shares held in a publicly traded corporation if the shares were not received as compensation after the initiation of
debarment from an entity bidding or performing work on a public works project.
Question 16: NAICS Code – This is optional.
Applicant Statement: Review the Applicant Statement, sign and date the Statement, and print the name and title
of the person signing the Statement.
Return application & payment to: UPS & FedEx overnight mail:
NJ Dept. of Labor & Workforce Development NJ Dept. of Labor & Workforce Development
Division of Wage & Hour Compliance Division of Wage & Hour Compliance
PO Box 389 1 John Fitch Plaza, 3
rd
Floor
Trenton, NJ 08625-0389 Trenton, NJ 08611
Tel. (609) 292-9464 Fax (609) 633-8591 Email: pwcr@dol.nj.gov
*** Please allow 30 calendar days for processing the contractor registration certificate. ***
*** Please keep a copy of your application for your records. ***
Check your registration status and effective and expiration dates online at www.nj.gov/labor
(click on Wage & Hour then Registration & Permits).
Failure to disclose associations with other firms or to disclose any prior history of
alleged violations could lead to the denial or loss of your contractor registration.
Pursuant to N.J.A.C. 12:62-2.4(a), a contractor registration certificate may be denied,
suspended, or revoked due to inaccurate information, misstatements, or omissions.
LSSE-2 (R-9-23-15) Page 1 of 4
STATE OF NEW JERSEY
Department of Labor and Workforce Development
Division of Wage and Hour Compliance
APPLICATION FOR PUBLIC WORKS
CONTRACTOR REGISTRATION
New Application - $300 Non-Refundable Fee Two-Year Renewal - $500 Non-Refundable Fee (o
nly available to firm
One-Year Renewal - $300 Non-Refundable Fee who have
been continuously registered for the past two consecutive years)
Current Certificate No. ___________________________
1. _______________________________________________________________________________________________________________
Business Name (Provide the name of business used to contract/subcontract public works projects.)
2. _______________________________________________________________________________________________________________
Legal / Corporate Name (If business entity is a sole proprietorship or partnership, enter name of owner or partners.)
3. _______________________________________________________________________________________________________________
Street Address (Do not use a PO Box) City State ZIP Code County
4. _______________________________________________________________________________________________________________
Mailing Address (Mailing address to which notices and the Public Works Contractor Registration certificate will be mailed.)
5. _______________________________________________________________________________________________________________
Telephone No. Fax No. Email Website
6. FEIN (Federal Employer Identification Number): * _____ _____ _____ _____ _____ _____ _____ _____ _____
* Any business that has employees and/or pays any kind of taxes must have a FEIN. If you are a sole proprietorship with no employees and
do not have an assigned FEIN from the IRS, you may provide your SSN; if so please indicate you are providing your SSN.
7a. Type of Business: Individual/Sole Proprietor Partnership NJ Corporation Out-of-State Corporation
LLC (Limited Liability Company) LLP (Limited Liability Partnership) Other __________________ State of Incorporation __________
Date of Incorporation/Formation _____/_____/__________ NJ Business/Corp. No. ___________________ Total Employees _____________
7b. Out-of-State Applicants: You must appoint a Registered Agent in New Jersey who will accept legal service in New Jersey.
New out-of-state applicants who plan to keep payroll/business records outside of NJ must complete a Request for Permission to Maintain Payroll
Records Outside of NJ (form MW-42). To get this form, go to www.nj.gov/labor and click on Wage & Hour then Registration & Permits.
____________________________________________________________________________________________________________
Name of Registered Agent in New Jersey
____________________________________________________________________________________________________________
Street Address City State ZIP Code
____________________________________________________________________________________________________________
Telephone No. Fax No. Email
8. Workers’ Compensation Carrier Name: * ___________________________________________________________________________________
Expiration date must be at least
Policy No.: ___________________________________ Effective _____/_____/_______ To _____/_____/_______ 30 calendar days from today.
* IF you are a sole proprietorship, partnership or limited liability company (LLC) with NO workers’ compensation coverage and NO employees
(excluding the principal owner, partners or members of the LLC), you must complete the below certified statement.
I certify that I am a sole proprietor, partnership or LLC with no workers’ compensation coverage and I have no employees.
___________________________________________ __________________________________________________ __________
Signature Print Name and Title Date
All applications must be accompanied by a check or money order made payable to the
Commissioner of Labor
and Workforce Development. We do not accept cash.
FOR OFFICE USE ONLY:
Log # __________________________
Check # _______________________
Check Amount $ _________________
_______________
Business Name: _________________________________________ Certificate No. _____________________
LSSE-2 (R-9-23-15) Page 2 of 4
9. Responsible Owners/Officers: Provide the following information for each individual with a financial interest in the business – except
that if the business is a publicly traded corporation – the corporation’s officers. Attach additional sheets if necessary.
NOTE: The names and titles of the individual owners, partners, or responsible corporate officers will be listed on the certificate.
a. ___________________________________________________________________________________________________________
First Name Last Name Title
___________________________________________________________________________________________________________
Social Security No. % of financial ownership in business (if zero, so state) Telephone No.
___________________________________________________________________________________________________________
Home Address City State ZIP Code
b. ___________________________________________________________________________________________________________
First Name Last Name Title
___________________________________________________________________________________________________________
Social Security No. % of financial ownership in business (if zero, so state) Telephone No.
___________________________________________________________________________________________________________
Home Address City State ZIP Code
c. ___________________________________________________________________________________________________________
First Name Last Name Title
___________________________________________________________________________________________________________
Social Security No. % of financial ownership in business (if zero, so state) Telephone No.
___________________________________________________________________________________________________________
Home Address City State ZIP Code
10. At any time during the preceding five (5) years, have any of the individuals listed in item #9 ever held an “interest” (for definition of
“interest,” see N.J.A.C. 12:60-7.2 in the instructions) in another firm which has applied for or obtained a “Public Works Contractor
Registration Certificate” or has bid on or performed work on a public works project, whether as an owner, partner, managing member (for
LLC companies only), corporate officer, principal, manager, employee, agent, consultant, or representative? Yes No
If yes, list the name of the individual, position held, start and end dates, and name and address of company.
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
NOTE: Failure to disclose associations with other firms could cause the denial or loss of your contractor registration certificate.
11. Has the business listed in item #1 ever been prohibited or debarred from performing public work (including voluntary prohibition) by
the State of New Jersey, any other state, public entity (e.g. city, county, board of education, etc.), or the federal government?
Yes No
If yes, provide start and end dates, reason for prohibition/debarment, and any other relevant details.
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
12. Have any of the individuals listed in item #9 ever been prohibited or debarred from performing public work (including voluntary
prohibition) by the State of New Jersey, any other state, public entity (e.g. city, county, board of education, etc.), or the federal
government? Yes No
If yes, list the name of the individual, start and end dates, reason for prohibition/debarment, and any other relevant details.
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
Business Name: _________________________________________ Certificate No. _____________________
LSSE-2 (R-9-23-15) Page 3 of 4
13. At any time during the preceding five (5) years, did the business listed in item #1 receive a notice of an alleged violation of any:
a. New Jersey State Labor Law? Yes No If yes, explain: __________________________________
b. United States Federal Labor Law? Yes No If yes, explain: __________________________________
c. Labor Laws of any other state or public entity? Yes No If yes, explain: __________________________________
NOTE: Failure to disclose any prior history of alleged violations could cause the denial or loss of your contractor registration certificate.
14. At any time during the preceding five (5) years, did any of the individuals listed in item #9 or any firm listed in item #10 receive a notice
of an alleged violation of any:
a. New Jersey State Labor Law? Yes No If yes, explain: __________________________________
b. United States Federal Labor Law? Yes No If yes, explain: __________________________________
c. Labor Laws of any other state or public entity? Yes No If yes, explain: __________________________________
NOTE: Failure to disclose any prior history of alleged violations could cause the denial or loss of your contractor registration certificate.
15. Has the firm or any individual listed in item #9 ever been alleged to have committed any unlawful act in attempting to obtain or in the
performance of a Public Contract? Yes No
If yes, name of public entity:____________________________________________________________Year: _______________________
16. Please place a check mark next to each North American Industry Classification System (NAICS) code that your company intends to
perform.
Your selection(s) will not limit the firm’s eligibility to perform any particular type of work.
Code
Craft
Craft
Code
Craft
238220
Air Balancing & Testing
Elevators
237310
Paving
562910
Asbestos Removal
Excavation
237120
Pipeline Construction
238910
Boring
Fencing
238220
Plumbing
238140
Brick and Block
Flooring/Tile
238220
Refrigeration
237990
Bulkheads & Docks
General Construction
238160
Roofing
238350
Carpentry (general)
Road and Heavy Highway
237110
Sewer Piping & Storm
Drains
238330
Carpeting
Hauling
238220
Sheet Metal (Mechanical)
238390
Caulking & Water Proofing
HVAC
238220
Sprinkler Systems
238110
Concrete
Iron and Steel Fabrications
517110
Telecommunications
213112
Core Drilling
Insulation/Mechanical
238210
Traffic Signals
238910
Demolition
Janitorial Services
562211
Waste Removal,
Toxic/Hazardous
561990
Diving
Landscape Construction
238190
Welding
237990
Dredging
Mechanical Construction
213111
Well Drilling
238210
Electrical
Painting
Other
Describe: ______________
Business
Name:
Certificate
No.
APPLICANT STATEMENT
I hereby certify, as a representative of the contractor named above and on behalf of the contractor named above, for whom
this Application is submitted, that it is understood that any Public Works Contractor Registration and receipt of any
public works funds and contracts are fully conditioned on the compliance of the contractor and all of its owners, officers,
directors, shareholders, founders, managers, agents, servants, employees, representatives and/or independent contractors
with all applicable state and federal laws, including all federal and state affirmative action requirements, all federal and
state prevailing wage requirements, as well and any other labor laws, statutes, rules and/or regulations, including the New
Jersey Wage Payment Law, N.J.S.A. 34:11-56 et seq., the New Jersey Prevailing Wage Act, N.J.S.A. 34:11-56.25 et seq.,
and all related laws, statutes, rules and regulations. It is further understood that the above contractor’s Public Works
Contractor Registration may be denied, suspended or revoked, and any subsequent public works funds and/or contracts
will be received in violation of this certification and the law, and the contractor named above and its owners, officers,
directors, shareholders, founders, managers, agents, servants, employees, representatives and/or independent contractors
may also be subject to suspension pending debarment, debarment, repayment of funds to public agencies, payment of
back wages to employees, and payment of other damages and/or civil penalties under the New Jersey Wage Payment
Law, N.J.S.A. 34:11-56 et seq., and the New Jersey Prevailing Wage Act, N.J.S.A. 34:11-56.25 et seq., as well as other
related laws, statutes, rules and regulations, including the New Jersey False Claims Act, N.J.S.A. 2A:32C-1 et seq.
In accordance with the New Jersey Child Support Improvement Act, N.J.S.A. 2A:17-56.44d, by signing this application I
am hereby certifying that I do not have a child support obligation or I have such an obligation but the arrearage amount
does not equal or exceed the amount of the child support payable for six months and any court-ordered health coverage
has been provided for the past six months. Furthermore, I certify that I have not failed to respond to a subpoena relating
to a paternity or child support proceeding or I am not the subject of a child support related warrant. I understand that
making a false statement may subject my contractor registration certificate to immediate revocation or suspension.
Signature of Contractor Representative Date
Print Name and Title
Return to:
NJ Dept. of Labor and Workforce Development
Division of Wage and Hour Compliance
PO Box 389
Trenton, NJ 08625-0389
Tel. (609) 292-9464
Fax (609) 633-8591
Email: pwcr@dol.nj.gov
UPS & FedEx overnight mail:
NJ Dept. of Labor and Workforce Development
Division of Wage and Hour Compliance
1 John Fitch Plaza, 3
rd
Floor
Trenton, NJ 08611
*** Please allow 30 calendar days for processing the contractor registration certificate. ***
*** Please keep a copy of your application for your records. ***
Check your registration status and effective and expiration dates online at www.nj.gov/labor
(click on Wage & Hour then Registration & Permits).
LSSE-2 (R-9-23-15) Page 4 of 4
IF YOU MAINTAIN YOUR
PAYROLL RECORDS OUTSIDE OF
NEW JERSEY, YOU MUST
COMPLETE THE FOLLOWING
APPLICATION.
State of New Jersey
Department of Labor and Workforce Development
Division of Wage and Hour Compliance
PO Box 389
Trenton, NJ 08625-0389
Application for Permit to Maintain Payroll Records Outside of New Jersey
Signature of Authorized Representative Print Name and Title Date
MW-42 (R-6-13)
1. Name and Address of Employer for which Permit is requested:
__
Federal Employer Identification Number (FEIN)
County
Telephone #
Fax #
E-Mail Address
Website Address
2. Name and Address of Out-of-State Location where records will be maintained
(if different from above):
County
Telephone #
Fax #
E-Mail Address
Website Address
3. Establishments in New Jersey for which request is being made (leave blank if not applicable):
Name and Address Phone # Fax # E-Mail Address Website Address
1)
2)
3)
4. Pay Period Ends (Day of Week) 5. Scheduled Payday (Day of Week)
6. Method of Payment
Check Cash
7. Des
cribe
form of record keeping (time cards, ADP payroll, etc.)
I certify that all payroll records will be made available in the State of New Jersey upon request to authorized representatives of the
Department of Labor and Workforce Development within 10 days of request. Furthermore, I certify that to the best of my knowledge
and belief, all statements in this application are true and correct.
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State Of New Jersey Instructions For Completing The (Town of Secaucus, New Jersey)

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Completed 18 July 2020

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