DLSE 704 A 1 State of California Department of Industrial Relations DIVISION OF LABOR STANDARDS ENFORCEMENT AMENDED EMPLOYER DISCLOSURE STATEMENT: USE OF FOREIGN LABOR CONTRACTOR Instructions:AmendmentstotheEmployerDisclosureStatement:UseofForeignLaborContractormustbesubmittedtotheLaborCommissionerbyemailatforeignlaborcon@dir.ca.govorbymailto:Labor Commissioner,Licensing&RegistrationUnitFnLC,1515ClayStreet,Suite401,Oakland,CA94612withinfifteen(15)daysofthechange.Pleaseindicatedateofinitialorpreviousdisclosure,employername(legaland223doingbusiness224asname,ifdifferent),provideupdatedinformationforanycategoryofinformationthathaschanged,andsigntheamendeddisclosure.DateofInitialorPreviousDisclosure: EmployingPerson222sFullLegalName: AllnamesunderwhichEmployingPersonisdoingbusinessas,orhasdonebusinessas,withinthe previousthree(3)years: EmployingPerson222scontactinformation: Currentphysicalbusinessaddress(number, street, city or town, county, state, zip code):Preferredmailingaddress(ifdifferent):Preferredemailaddress:Homeaddress(ifsoleproprietor):Foreignaddress,ifapplicable:Mainbusinessphonenumber:Mobilephonenumber: American LegalNet, Inc. www.FormsWorkFlow.com DLSE 704 A 2 Employer222sdesignatedpersontoworkwithForeignLaborContractor: Nameandposition:Currentphysicalbusinessaddress(number, street, city or town, county, state, zip code):Preferredmailingaddress(ifdifferent):Preferredemailaddress:Mainbusinessphonenumber:Designatedperson222smobilephonenumber:Employer222soperationalinformation: Typeofbusinessoperatedbyemployer(specifyindustryandgoodsand/orservicesprovided):Physicaladdress(es)ofbusinesslocation(s)whereforeignguestworkerswillwork:Numberofforeignguestworkersthatwillperformlaborforemployer:Timeperiodduringwhichforeignguestworkerswillperformlaborforemployer:Visaclassificationsauthorizingforeignguestworkerswhowillperformlaborforemployer:Nameandbriefdescriptionofpositionstobefilledbyforeignguestworkers:NumberofForeignLaborContractorsemployerwillusetosolicitorrecruitforeignguestworkers: American LegalNet, Inc. www.FormsWorkFlow.com DLSE 704 A 3 ForeignLaborContractor(s)involvedinrecruitingemployeesonbehalfoftheemployer: Name:Currentphysicalbusinessaddress(number, street, city or town, county, state, zip code):Mailingaddress(ifdifferent):Emailaddress:Mainbusinessphonenumber:Mobilephonenumber:(IfthereareadditionalForeignLaborContractorswhoarerecruitingemployeesonyourbehalf,pleaseincludecontactinformationonaseparatepage.)***Icertifythat(EMPLOYINGPERSON)willnotknowinglyenterintoanagreementfortheservicesofaforeignlaborcontractorthatisnotregisteredundertheBusinessandProfessionCode2479998.1.5.PursuanttoBusinessandProfessionsCode2479998.1.5(b)(2),IconsenttothedesignationoftheLaborCommissionerasanagenttoacceptserviceofsummonsinanyactionagainst(EMPLOYINGPERSON),if(EMPLOYINGPERSON),and/or(EMPLOYINGPERSON)222sdesignatedagentforserviceofprocesshasleftthejurisdictioninwhichtheactioniscommencedorotherwisehasbecomeunavailabletoacceptservice.Executedat,California,thisdayof20.Signature:PrintName&Title: American LegalNet, Inc. www.FormsWorkFlow.com