Professional Employer Organization Limited License Application · Professional Employer...

CSCL/PEO-020 (02/2020) Page 1 of 1 Corporations, Securities & Commercial Licensing Licensing Division P.O. Box 30018, Lansing, MI 48909 517-241-9221 www.michigan.gov/peo FEES ARE AUTHORIZED UNDER 2010 PA 370 ARE NOT REFUNDABLE. LARA is an equal opportunity employer/program. Auxiliary aids, services and other reasonable accommodations are available upon request to individuals with disabilities. Name Address Taxpayer ID # or EIN ZIP Code City State Telephone Number E-mail ( ) PROFESSIONAL EMPLOYER ORGANIZATION LIMITED LICENSE APPLICATION AUTHORITY: 2010 PA 370 PENALTY: FAILURE TO PROVIDE THIS INFORMATION MAY RESULT IN DENIAL OF THE APPLICATION AND/OR DISCIPLINARY ACTION Make your check or money order in U.S. Currency payable to: STATE OF MICHIGAN FOR OFFICE USE ONLY FOR OFFICE USE ONLY FEE PAYMENT INFORMATION (Check One Box) Professional Employer Organization Application and License Fee December 1 through February 28 $2,753.00 7202-01 September 1 through November 30 $3,171.00 7202-01 March 1 through April 30 $2,335.00 7202-01 May 1 through August 31* $3,171.00 7202-01 *If payment received during this time frame, the expiration date will be August 31 of the following year. Do you maintain an office in Michigan? Do you directly solicit clients in Michigan? Certification I certify that the statements in this document are true and complete. I understand that any omitted statement, misrepresentation, or fraud may be cause for denial of my application, disciplinary action, or may be punishable by law. Signature Date No Yes No Yes No Yes Do you have more than 50 covered employees employed or domiciled in Michigan on any given day? Required Documents Provide a copy of valid license or certificate of regulation from another state as a PEO. Approved By: Date Approved: License Number:

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Transcript of Professional Employer Organization Limited License Application · Professional Employer...

Page 1: Professional Employer Organization Limited License Application · Professional Employer Organization Application and License Fee December 1 through February 28 $2,753.00 7202-01 September

CSCL/PEO-020 (02/2020)Page 1 of 1

Corporations, Securities & Commercial Licensing Licensing Division

P.O. Box 30018, Lansing, MI 48909517-241-9221

www.michigan.gov/peo

FEES ARE AUTHORIZED UNDER 2010 PA 370 ARE NOT REFUNDABLE.

LARA is an equal opportunity employer/program. Auxiliary aids, services and other reasonable accommodations are available upon request to individuals withdisabilities.

Name

Address

Taxpayer ID # or EIN

ZIP CodeCity State

Telephone Number E-mail

( )

PROFESSIONAL EMPLOYER ORGANIZATION LIMITED LICENSE APPLICATIONAUTHORITY: 2010 PA 370

PENALTY: FAILURE TO PROVIDE THIS INFORMATION MAY RESULT IN DENIAL OF THE APPLICATION AND/OR DISCIPLINARY ACTION

Make your check or money order in U.S. Currency payable to:

STATE OF MICHIGAN

FOR OFFICE USE ONLY FOR OFFICE USE ONLYFEE PAYMENT INFORMATION (Check One Box)

Professional Employer Organization Application andLicense Fee

December 1 through February 28 $2,753.00 7202-01

September 1 through November 30 $3,171.00 7202-01

March 1 through April 30 $2,335.00 7202-01

May 1 through August 31* $3,171.00 7202-01

*If payment received during this time frame, the expirationdate will be August 31 of the following year.

Do you maintain an office in Michigan?

Do you directly solicit clients in Michigan?

Certification

I certify that the statements in this document are true and complete. I understand that any omitted statement, misrepresentation, or fraudmay be cause for denial of my application, disciplinary action, or may be punishable by law.

Signature Date

NoYes

Do you have more than 50 covered employees employed or domiciled in Michigan on any given day?

Required Documents

Provide a copy of valid license or certificate of regulation from another state as a PEO.

Approved By: Date Approved:

License Number: