Professional Employer Organization Request for Limited Registration PEO-4

Professional Employer Organization Request for Limited Registration

PEO-4
Qualification for Limited Registration
A PEO can request a limited registration if:
• It does not maintain an office in Connecticut, AND
• It does not engage in direct solicitation of business in Connecticut, AND
• It does not have more than fifty (50) worksite employees in Connecticut, AND
• It is licensed to do business as a PEO in another state, AND
• It is domiciled outside this state.

If all of the above requirements are met, complete this form. If any of the requirements are not met, the PEO must complete Request for Registration for PEO (PEO-1).

This form must be completed and printed by the applicant. The printed form should then be mailed per the instructions detailed within this Knowledge Base article.

Please ensure that any of the other required documents/statements for your application are included and mailed at the same time.
Type of Request (check one)
Name of Professional Employer Organization:
Additional names, if any, under which the PEO currently conducts business:
Type of business organization (mark one):
Federal Employer Identification Number (FEIN):
Connecticut Unemployment Insurance Employer Registration Number:
Complete physical address of Principal Administrative Office:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mailing address, if different:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number of Principal Administrative Office:

Area CodePhone Number
Fax Number of Principal Administrative Office:

Area CodePhone Number
Email of Principal Administrative Office:
example@example.com
States in which the PEO is licensed or registered as PEO, its licenses or registration number, and the State Agency that issued it:
Fiscal Year Starts:

MonthDayYear
Fiscal Year Ends:

MonthDayYear
LIST OF ALL CLIENTS OF THE PEO OR THE PEO GROUP
This form allows input of up to three client companies. Please use a separate sheet of paper if needed to list all client companies.

For each client company include:
- Client company name
- Client company address (physical location)
- Client company state tax ID number
- Connecticut Unemployment Insurance Employer Registration Number
Client Company Name:
Client Company Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Client Company State Tax ID Number:
Connecticut Unemployment Insurance Employer Registration Number:
Add another client company:
Client Company Name:
Client Company Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Client Company State Tax ID Number:
Connecticut Unemployment Insurance Employer Registration Number:
Add a third client company:
Client Company Name:
Client Company Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Client Company State Tax ID Number:
Connecticut Unemployment Insurance Employer Registration Number:
Should be Empty:

Professional Employer Organization Request for Limited Registration

Qualification for Limited Registration

LIST OF ALL CLIENTS OF THE PEO OR THE PEO GROUP