Application/Renewal for Employee Fee Paid Employment Agency Registration

In order to apply or renew your registration this form must be completed, signed and mailed to the address below (please do not forget to include the $150.00 fee):

Connecticut Labor Department
Wage & Workplace Standards Division
200 Folly Brook Boulevard
Wethersfield, CT 06109-1114
Telephone: (860) 263-6791

If you should have Questions concerning this application please use the same address and/or telephone number for assistance.

Application/Renewal must be accompanied by:

♦ A check or money order for the required registration fee of $150.00 payable to the Connecticut Department of Labor.

♦ A certificate of assumed or trade name as filed in Town Clerk’s office if applicant is sole-proprietor or partnership.

♦ If a corporation/limited liability company/limited liability partnership, your status as a Connecticut corporation/limited liability company/limited liability partnership, or authority to do business in Connecticut must be on file with the Connecticut Secretary of States’ office. A search will be conducted by this office to make sure your business is registered with the Connecticut Secretary of States’ office. If records do not indicate that you are active and in good standing, we will be in touch with your agency for additional paperwork.

♦ Proof of Workers’ Compensation insurance with complete Workers’ Compensation Information form (PROOF OF WORKERS’ COMPENSATION IS A CERTIFICATE OF INSURANCE ) Corporations or Limited Liability Companies with no employees can be exempted from carrying Workers’ Compensation Insurance for their officers or members by completing a Workers’ Compensation Form 6b. Partnerships or Limited Liability Partnerships with no employees can be exempted from carrying Workers’ Compensation Insurance by having the partners complete a Workers Compensation Form 6b1. More information on Form 6b and 6b1 can also be found here. The original forms should be submitted to your local Workers’ Compensation District office and copies sent to our office with your registration forms and fee.

The following should be complied with:

♦ Contact the Department of Revenue Services at (860) 297-5962 for sales tax regulations required on agency fees.

♦ Contact Wage & Workplace Standards Division at (860) 263-6790 for wage and hour regulations.

♦ See the link regarding employer | employee reposibilities for Unemployment Benefits: Employers

Application for Employer Fee Paid Employment Agency Registration

I, (We) hereby apply for a registration:

Doing Business as:

Business Address (only Connecticut addresses will be accepted):

Street Address

Street Address Line 2

City

Postal / Zip Code

Business Telephone Number:

Area CodePhone Number

Email Address:

Secretary of State Filing Number for the current year (10-digit number):

Owner is:

If business is:
• Sole Proprietorship - list owner
• Partnership - list all partners
• Corporation - list all officers and directors.
• Limited Liability Corporation - list all members.

Name:

First NameLast Name

Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Title:

Add another name:

Name:

First NameLast Name

Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Title:

Add a third name:

Name:

First NameLast Name

Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Title:

Please provide your social security number(SSN) or your federal employer identification number (FEIN) .

I (We) certify that the information provided on this application for Employer Fee Paid Employment Agency Registration is true and
accurate

Signature

Date:

MonthDayYear

Additionl Locations:

Important

Worker's Compensation Insurance

You MUST print and return this form with the requested information

Section 31-286a of the Connecticut General Statues requires that any applicant for a license or permit and/or renewal of the license or permit who has employees in the State of Connecticut must first provide a CURRENT certificate of Worker's Compensation Insurance in order for us to ISSUE or RENEW YOUR LICENSE or REGISTRATION.

Sample Worker's Compensation Insurance certificate (for review purposes only)

6B Coverage Election by Employees who is an Officer of a Corporation, Manager of an LLC, or Member of a Multiple -Member LLC

6B-1 Coverage Election by Employees who are Members of a Partnership.

Please check one (1) box:

Business Name:

Business Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Your Name:

First NameLast Name

Signature:

Email

example@example.com

Date:

MonthDayYear