Form Erd-12192 - Employment Agent'S Registration printable pdf download

Form Erd-12192 - Employment Agent'S Registration

Wisconsin Department of Workforce Development

Equal Rights Division – Labor Standards Section

Personally identifiable information may be used for secondary purposes. See Section 15.04(l)(m), Wis. Stats. for details.

EMPLOYMENT AGENT’S REGISTRATION

Name of Proposed Agency:

___________________________________________

Street Address:

___________________________________________

City, State, Zip Code:

___________________________________________

Type of Ownership:

Corporation

Partnership

Individual Proprietorship

(Circle One)

Owner(s) Name, Home Address: (List each stockholder, partner or owner)

Name:

____________________________________

Address:

____________________________________

Name:

____________________________________

Address:

____________________________________

Name:

____________________________________

Address:

____________________________________

Registration Check

for $5.00 should be made payable to the EQUAL RIGHTS DIVISION

Any questions, you may call (608) 266-0030 for assistance.

RETURN COMPLETED REGISTRATION FORM & CHECK TO:

EQUAL RIGHTS DIVISION

PO BOX 8928

MADISON WI 53708-8928

PLEASE STAPLE CHECK HERE TO BOTTOM OF THE FORM.

ERD-12192 (R. 012/2000)

Form Erd-12192 - Employment Agent'S Registration