FORM PEO � REVISED 04/2014 STATE OF HAWAII DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS PROFESSIONAL EMPLOYER ORGANIZATION (PEO) PROGRAM APPLICATION FOR PROFESSIONAL EMPLOYER ORGANIZATION REGISTRATION IN THE STATE OF HAWAII Pursuant to the provisions of Hawaii Revised Statutes (HRS) Chapter 373L concerning Professional Employer Organizations, the undersigned hereby makes the following statements for the purpose of obtaining a registration to conduct business as a Professional Employer Organization ("PEO") in the State of Hawaii: Initial Application _________ Biennium Renewal ___________ Restoration Application __________ Every Applicant for an initial application or renewal application shall file with the Hawaii Department of Labor and Industrial Relations (the "Department") a completed application form with required fee. Pursuant to Chapter 373L, HRS, effective July 1, 2013, the following fees are applicable: (1) Initial Registration fee (2) Biennial Renewal fee (3) Restoration fee $500.00 $750.00 $1,500.00 All checks for the above fees shall be made out to the "State of Hawaii, Director of Finance". GENERAL INFORMATION Name of PEO _________________________________________________________________________ Type of business organization: (check one) ___ Sole Proprietorship ___ Limited Partnership ___ Corporation ___ LLC ___ S Corporation ___ Other ___ Partnership Employer Identification Number (EIN): __________________________________________________ Department of Labor Number (DOL No.) __________________________________________________________________ General Excise Tax Number: ___________________________________________________________ Please list names under which PEO conducts or will conduct business: ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ American LegalNet, Inc. www.FormsWorkFlow.com PRINCIPAL PLACE OF BUSINESS Address: ____________________________________________________________________________ City: __________________ Telephone: _____________ State: ____________ Fax: _____________ Zip: __________________________ Website: ______________________ OTHER OFFICES: (located in Hawaii Only) Address: ____________________________________________________________________________ City: __________________ Telephone: _____________ State: ____________ Fax: _____________ Zip: __________________________ Website: ______________________ Address: _____________________________________________________________________________ City: __________________ Telephone: _____________ State: ____________ Fax: _____________ Zip: __________________________ Website: ______________________ PRIMARY CONTACT PERSON AND BUSINESS ADDRESS Name of Primary Contact Person: ______________________________________________________ Address: ____________________________________________________________________________ City: __________________ Telephone: _____________ State: ____________ Fax: _____________ Zip: _________________________ Email: ________________________ LIST OF ADDITIONAL BUSINESS NAMES Please provide a list, organized by jurisdiction (City, State, Street Address), of each name under which the PEO has operated in the preceding five years, including any alternative names, names of predecessors, and if known, names of successor business entities: _____________________________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ 2 American LegalNet, Inc. www.FormsWorkFlow.com CONTROLLING PERSONS' INFORMATION: All persons who constitute a Controlling Person pursuant to Chapter 373L (HRS) must be listed below, along with the applicable and requested information for each Controlling Person. Each registered PEO must have at least one properly identified Controlling Person. Controlling Persons Based on Ownership: Please provide the below requested information regarding each person who, individually or acting in concert with any other person or persons, owns or controls, directly or indirectly, twenty-five percent or more of the equity interests of the PEO: Full Name and Address Phone % Ownership Management: Please provide the below requested information regarding any person who serves as President or Chief Executive Officer of the PEO or who otherwise has the authority to act as a senior executive officer of the PEO and execute contracts on behalf of the PEO: Full Name and Address Title/Position Phone FINANCIAL INSTITUTION USED FOR PAYROLL Financial Institution located in Hawaii: _________________________________________________ Address: _________________________________________________________________________ City: _____________________________________________________________________________ State: ____________________________________________________________________________ Zip: _____________________________________________________________________________ Telephone:_____________________________ Fax: ______________________________________ Email: ___________________________________________________ REQUIRED DOCUMENTS: 3 American LegalNet, Inc. www.FormsWorkFlow.com 1. Provide a copy of the certificate of authority to transact business in this state, issued by the Director of Commerce and Consumer Affairs, pursuant to Title 23 or Title 23A, if applicable. 2. Provide a copy of the State of Hawaii Certificate of Vendor Compliance which shows a current COMPLIANT status. This is obtained through the Hawaii Compliance Express electronic system via the ehawaii.gov website. 3. Provide the name of each client company that is a party to a professional employer agreement with your company. Each client company name shall be provided to the department within twenty-one days of the initiation of the agreement and within twenty-one days of the termination of the agreement. 4. Provide a copy of the Internal Revenue Service Form W-3 that was most recently filed with the federal government. 5. Provide a surety bond or irrevocable letter of credit equivalent to the required bond amount, which is based on the previous year's payroll of the professional employer organization based on the Internal Revenue Service For