Application for Private Employment Agency License

Application for Private Employment Agency License
Please complete the form, print and mail to the following address:

State of Connecticut
Department of Labor
Wage and Workplace Standards Division
200 Folly Brook Blvd
Wethersfield, CT 06109
Type of License:
I (We) hereby apply for a license to conduct a private employment agency:
Name under which agency will do business:
Address where agency will do business (only Connecticut addresses will be accepted):

Street Address

Street Address Line 2

CityState

Zip Code
Business Phone Number:

Area CodePhone Number
Email Address:
example@example.com
Owner is (check one):
Type of Placements:

Other
List schedule of fees-Fee: Percentage is limited to first years starting salary. Fees must be listed - Do not attach schedule.
Applicant:
Employer:
Do you need to add another Applicant and Employer:
Applicant:
Employer:
Do you need to add a third Applicant and Employer:
Applicant:
Employer:
I (We) certify that the information provided on this application for Employer Fee Paid Employment Agency Registration is true and accurate:

First NameLast Name
Signature:
Date:

MonthDayYear
Should be Empty: