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Pennsylvania Private Employment Agency License Application

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Pennsylvania Private Employment Agency License Application Powered By Docstoc
					LIBE-377   REV 11-97                               APPLICATION
       COMMONWEALTH OF PENNSYLVANIA                    FOR                          Date ____________________
      DEPARTMENT OF LABOR AND INDUSTRY
 BUREAU OF OCCUPATIONAL AND INDUSTRIAL SAFETY
                                                EMPLOYMENT AGENCY
             HARRISBURG, PA 17120                    LICENSE                        Class ____________________

Application for license to operate as Employment Agent in Pennsylvania as provided in Act No. 261, July 31, 1941.

This application to be completed and submitted to the Department of Labor and Industry, Private Employment
Agency Licenses, 155E Labor and Industry Building, 7th and Forster Streets, Harrisburg, PA 17120-0019.


THE FOLLOWING MUST BE SUBMITTED WITH THIS APPLICATION:

     (a) LICENSE FEE in the amount of $300.00 for either a Class 1 or Class 2 license as provided in Section 10
         of Act No. 261. Such license fee must be in the form of a certified check, cashier’s check or postal money
         order payable to the Commonwealth of Pennsylvania.

     (b) BOND of a duly-authorized surety company in the penal sum of $3,000.00 payable to the Common-
         wealth of Pennsylvania as provided in Section 9 of Act No. 261.

     (c) PROPOSED CONTRACT and SCHEDULE OF FEES as provided in Section 11 of Act No. 261.

When this application with necessary license fee, bond, contract and schedule of fees is received by the
Department of Labor and Industry, the procedure outlined in Section 6 of Act No. 261 will be followed.


INFORMATION REQUIRED FROM APPLICANT FOR LICENSE:

Name under which agency will be operated ___________________________________________________________

 ________________________________________________________________________
_________________________________________________________________________

Location of agency:

                Street and Number ______________________________________________________________________

                City, State and Zip Code __________________________________________________________________

                Telephone No. _____________________________      County ___________________________________


Owner or owners of agency; Partners if partnership; Office if corporation:
(Give names and home addresses of each.)

_________________________________________________________________________________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________



                                                        -1-
                                           LICENSE CLASSIFICATION

Please indicate type of license desired:

Class 1 - $300.00 license fee:

           Nurses
           Babysitters
           Domestic and unskilled labor
           Teachers
           Executives, managers, secretaries, office clerks, skilled laborers, technicians and others

Class 2 - $300.00 license fee:

           Actors, actresses, musicians and performers
           Models

Name and home address of person in charge of agency _________________________________________________

______________________________________________________________________________________________________

_________________________________________________________________________________________________

Owner of building in which agency will operate _________________________________________________________

Address of owner _________________________________________________________________________________
                                                     STREET

_________________________________________________________________________________________________
                       CITY                                 COUNTY                  STATE               ZIP CODE



Has applicant previously had license to operate an employment agency in PA?          Yes       No

If Yes, Where? _______________________________________ When? ____________________________________

In any other state?      Yes         No

If Yes, Where? _______________________________________ When? ___________________________________

Is applicant engaged in operating an employment agency or financially interested in any other place at
present?      Yes      No

If Yes, please designate name(s) and location(s) _______________________________________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________

Is agency a franchise?         Yes        No

If Yes, give name and address of franchisor ___________________________________________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________


                                                      -2-
                                EDUCATIONAL AND EMPLOYMENT HISTORY

                                            TYPE OR PRINT ALL INFORMATION
                        This must be completed for each applicant that is shown on Page 1.


Last Name                                   First                           Middle          Maiden Name


Social Security Number                      Work Telephone                  Home Telephone


Address                                             City                                    State     Zip Code


Date of Birth                Sex      Race



                                                    EDUCATION

High School                        Course                                                Diploma         Year
                                                                                                       Graduated


College or University              Major Study                Minor Study               Degree or        Year
                                                                                        Credit Hrs.    Graduated


Graduate School or Other           Course                                               Degree or        Year
                                                                                        Credit Hrs.    Graduated



                                            EMPLOYMENT RECORD

Dates       Employer’s Name and Address (Most recent position first)
From        Name                                                                     Position


To          Address                                                                  Supervisor


From        Name                                                                     Position


To          Address                                                                  Supervisor


From        Name                                                                     Position


To          Address                                                                  Supervisor



Does applicant have a criminal record?       Yes       No
A criminal background check will be done at our discretion.


                                                        -3-
                                                   AFFIDAVIT


           Commonwealth of Pennsylvania

County of __________________________________




_________________________________________________ being duly sworn, deposes and says that no person
other than those mentioned in the application is financially interested in the business to be carried on under the
license when issued, and that all statements made in this application are true and correct. Applicant further
affirms that he or she is fully aware of all applicable provisions of the Act of October 27, 1955, (P.L. 744), the
“Pennsylvania Human Relations Act,” as amended, and that the applicant has knowledge of the penalties that
may be imposed for violation of this Act.



                                                             _____________________________________________
                                                                          Signature of Applicant




Subscribed and sworn to before me this

_____ day of __________________________, ______

_____________________________________________
            Notary Public




                                                       -4-

				
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