Professional Employer Organization
Criminal History Form

Name of Controlling Person with Criminal History:
Name Percentage of Ownership
Crime(s) Committed:

You must submit the following attachments via email to with “PEO” in the subject line:


  1. Charging documents for each criminal incident;
  2. Sentencing documents for each criminal incident; and
  3. Written statement escribing the circumstances surrounding the incident(s).


Name of Person Submitting Application: 
Company:   Title: 
 By checking this box, I attest and affirm that I am authorized to submit this application on behalf of the applicant named herein, and that the information included is true, correct and complete to the best of my knowledge and belief. I understand that knowingly providing false or fraudulent information or knowingly make a material misrepresentation in connection with this application or any information or reports required under the Professional Employer Organization Registration Act, K.S.A. 44-1701 et seq., may result, inter alia, in the denial of the application, revocation of registration, or imposition of fines and penalties.

Date of Application: 05/19/2024