Date of Application: 12/12/2024
Type of Registration: PLEASE NOTE THAT ALL PEO REGISTRATION AND RENEWAL FEES SUBMITTED ARE NONREFUNDABLE Individual: $1000 Initial Registration, $500 Renewal Registration Group: $1000 per company Initial Registration, $500 per company Renewal Registration Limited: $500 Initial/Renewal Registration
Section One: General PEO Information Name of company(ies): DBA Name(s) of company(ies): Name(s) of Predecessor and/or Successor Business Entity(ies) within the past 5 years:
TYPE OF ENTITY: Sole Proprietorship Corporation Limited Liability Partnership Partnership Limited Liability Company Other (Submit Explanation)
If applying for a Group Registration, please submit a list containing the above information for all entities in the group. Website: Contact: Title:
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.
Full Legal Name: Additional Name(s): Title: Street Address:
Section Three: Financial Information Submit the most recent audited financial statements setting forth the financial condition of the PEO or PEO Group.