Form Erd-12192-E - Employment Agent Registration
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1Employment Agent Registration
State of Wisconsin
Department of Workforce Development
Equal Rights Division
NOTICE: Authorization for this form is provided under Chapter 105 Wisconsin Statutes and Section DWD
277.02 of Wisconsin Administrative Code. Use of this form is mandatory. This information is used for the
purpose of processing your application and maintaining the division’s records. Personal information you
provide may be used for secondary purposes [Privacy Law, s. 15.04(1) (m), Wisconsin Statutes].
Proposed Agency Name
Street Address
City
State
Zip Code
Telephone Number
WI
-
-
Type of Ownership
Corporation
LLC
Partnership
Individual Proprietorship
List the names and home addresses of all stockholders, partners or owners.
Name
Street Address
City
State
Zip Code
Telephone Number
WI
-
-
Name
Street Address
City
State
Zip Code
Telephone Number
WI
-
-
Name
Street Address
City
State
Zip Code
Telephone Number
WI
-
-
NEW
YES
NO
Does your agency engage in making home care placements?
A “home care placement” is the placement of any person in a private home to provide medical or
companionship care for a consumer. It includes situations where the consumer is employing the individual,
the worker is self-employed or the worker is employed by a third party.
Enclose a $5.00 check for the registration fee made payable to the
Equal Rights Division.
Return the completed form & check to:
EQUAL RIGHTS DIVISION
PO BOX 8928
MADISON WI 53708-8928
(608) 266-7560 for assistance
Please staple check HERE to the bottom of the form.
ERD-12192-E (R. 08/2010)
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