Worker Leasing License Application - Limited Internal use only Received date: Approved date: An applicant must file this form to obtain a limited license. The Oregon Workers222 Compensation Division will request the $2,050 fee once it has approved your license. The license expires two years after issuance, unless a new limited license application (Form 5362) is received and the license is renewed. [OAR 436-180-0140(6)] Email this application to WorkerLeasing.WCD@oregon.gov . If you have questions about this form, call 503-947-7544. Do not leave sections blank. Incomplete applications will not be accepted. To qualify for a limited license, the applicant must meet all of the following: Be licensed or certified in one of the states listed under item 3(c) below Have no more than two Oregon clients Have no more than a total of five leased workers in Oregon Be domiciled in a state other than Oregon Not maintain an Oregon location Not directly solicit clients located or domiciled in Oregon APPLICANT 1. Applicant information Full legal name: Assumed business name: FEIN: Yes No Does applicant also provide temporary workers under the same FEIN/entity in any state? Mailing address: Physical address: (If different from mailing address) 2. C ontact informati on Licensing contact Phone Email Secondary contact Phone Email Client proof of coverage contact Phone Email 3. Support ing documentation (a) Provide signed releases for tax compliance verification: Oregon Employment Department Oregon Department of Revenue Internal Revenue Service (b) Attach written procedures that demonstrate how the applicant will ensure its clients provide adequate training, supervision, and instruction to meet the requirements of ORS chapter 654. (c) Check all states where applicant is licensed or registered. For each, provide a copy of current license or registration. Alabama Florida Illinois Indiana Michigan Montana North Carolina South Carolina Texas 5362 440-5362 (7/18/DCBS/WCD/WEB) Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com 4. Client information Client legal name dba, if any FEIN Date of first payroll in Oregon Number of employees 5. Affidavit of applicant I, , acting on behalf of , as the applicant, first being duly sworn, say that, to the best of my knowledge, the applicant is qualified in all respects for the worker leas ing company license applied for in the Worker Leasing License Application Limited; that I have answered all of the questions in this application truthfully; that any and all supporting documents submitted with this application are true, correct, and valid; that there have been no material omissions of fact, which would have bearing on the division222s decision to grant the requested license; and this affidavit is provided by me in the regular course without fraud or misrepresentation. I hereby authorize all persons, institutions, organizations, schools, governmental agencies, employers, references, or any others set forth directly or by reference in this application, to release to the Workers222 Compensation Division, Department of Consumer and Business Services, State of Oregon, any files, records, or information of any type reasonably required for the division to properly evaluate the applicant222s qualifications to be licensed as a worker leasing company in Oregon. Under penalty of perjury, I declare that all information provided in this application and accompanying documents, or information I may yet provide to support this application, is true and correct and discloses all material facts regarding the applicant222s background and qualifications for licensing. I understand that furnishing false information or failing to disclose information regarding the applicant222s background and qualifications may be grounds for refusing to issue a license or to revoke a license issued. Signature of authorized representative Date of signature Verification upon oath or affirmation NOTARY PUBLIC SEAL State of County of Si g ned and sworn to or affirmed before me on , 20 . Notary Public My commission expires: 5362 440 - 5362 (7/18/DCBS/WCD/WEB) Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com