Professional Employer Organization (PEO) Application Form

Date of Application: 08/12/2022

Type of Registration:
$1000 Initial Registration, $500 Renewal Registration
$1000 per company Initial Registration, $500 per company Renewal Registration
$500 Initial/Renewal Registration

Section One: General PEO Information




Name(s) of Predecessor and/or Successor Business Entity(ies) within the past 5 years:

TYPE OF ENTITY:
             
             

FEIN: State Specific ID: Fiscal Year Ending:
Date of Organization: State of Organization: Articles of Incorporation submitted:
 
Street Address:
City: State: Zip:
Email: Fax: Business Phone:

If applying for a Group Registration, please submit a list containing the above information for all entities in the group.





Phone: Fax: Email:

1. Submit a list of jurisdictions in which the applicant(s) has operated in the past five (5) years.
2. Submit a list of all branch offices maintained by the PEO in Kansas, include address and phone.

Section Two: Controlling Person Information
Include the name and evidence of business experience for:
 1. any person(s) owning or controlling, directly or indirectly, 15% or more of the equity interest of the PEO
 2. any person(s) who serves as president, chief executive officer or otherwise has the authority to act as a senior executive officer of the PEO.








City: State: Zip:
Email: Phone: Fax:
Date of Birth: % Voting Interest/Ownership/Position:
Evidence of Business Experience (submit additional pages as needed):

 








City: State: Zip:
Email: Phone: Fax:
Date of Birth: % Voting Interest/Ownership/Position:
Evidence of Business Experience (submit additional pages as needed):

Section Three: Financial Information
Submit the most recent audited financial statements setting forth the financial condition of the PEO or PEO Group.

  • At the time of registration, audited financial statement shall not be older than 13 months.
  • If the closing date of the audited financial statements is older than three months from the date of application, the Applicant must also submit updated, though unaudited, financial statements for the most recent quarter, attested to by the CEO or CFO.
  • The financial statement shall be prepared in accordance with generally accepted accounting principles and audited by an independent certified public accountant licensed to practice in the jurisdiction in which such accountant is located, and shall be without qualification as to the going concern status of the PEO. A PEO Group may submit combined or consolidated audited financial statements to meet the requirements of this section. A PEO that has not had sufficient operating history to have audited financial statements based upon at least 12 months of operating history shall meet the financial capacity requirements of K.S.A. 44-1704 (f) and present financial statements reviewed by a certified public accountant.
Demonstrate positive working capital.
  • Applicants must maintain positive working capital upon registration as indicated in the financial statements,
    OR
  • Submit a bond, irrevocable letter of credit or securities with a minimum market value in an amount equal to the sum of the amount that would be necessary for such professional employer organization or professional employer group to comply with K.S.A. 44-1706 (a) plus $100,000 to the commissioner at such time as the professional employer organization or professional employer group does not have sufficient working capital.