To the ALABAMA
DEPARTMENT OF LABOR :
The undersigned, a professional employer organization
subject to the provisions of the Alabama Professional Employer Organization Registration
Act, as last amended, hereby registers for the privilege of operating as a limited
professional employer organization in the State of Alabama, and submits the following
facts under oath to the Alabama Department of Labor: |
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Professional Employer Organization
Information:
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Type of Registration: |
Initial Registration |
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Name of PEO: |
test |
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Date of Organization: |
2025-05-23 |
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Unemployment Compensation Account # |
1231231312323132 |
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Federal ID # |
123546789 |
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Business Address: |
test |
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City, State, Zip: |
test, Alabama 36109 |
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Telephone: |
3341234567 |
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Fax: |
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Web site: |
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Primary Contact Person:
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Name |
test test |
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Business Address: |
test |
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City, State, Zip: |
alabama, Kansas 36109 |
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Telephone: |
3341234567 |
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Fax: |
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E-Mail Address: |
pleasedelete@gmail.com |
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Organizational Structure
Information:
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| Organizational
Structure Type: |
Corporation
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| If registrant is a corporation, provide
the corporate name, if different than name of PEO, and the State in which
the Articles of Incorporation are filed. |
test |
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| Please provide a list, by jurisdiction,
of each name under which the registrant/PEO has operated in the preceding
five years, including any alternative names, names of predecessors and,
if known, successor business entities. |
test |
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Consolidated Registration :
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| Is the registrant company a part of
a group / multiple organizations? |
no
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| Note: A separate
registration fee for each PEO is still required. |
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Current Alabama Agent For Service of Process:
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Name : |
test t test |
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Business Address: |
test |
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City, State, Zip: |
test, Indiana 36209 |
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Telephone: |
3341234567 |
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Fax: |
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E-Mail Address: |
pleasedelte@gmail.com |
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Controlling Persons, Officers, and Directors :
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Controlling Persons Based on Ownership:
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| Full Name |
Full Address |
Date of Birth |
Percent Ownership |
Social Security Number / Federal Employer ID Number |
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Officers, Directors, Partners, and Controlling Persons Based on Position:
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| Full Name |
Title/Position |
Date of Birth |
Social Security Number |
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Registrant Business History:
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| 1.) Have any of the Registrant's proposed
controlling persons been convicted of or entered a guilty plea or a plea
of nolo contendere to: |
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a.) a crime in any jurisdiction which relates
to the operation of a professional employer organization or the ability
to engage in business as a professional employer organization? |
No |
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b.)Fraud, deceit, or misconduct in the
classification of employees or reporting of employee wages under the workers'
compensation laws in any jurisdiction or territory in the United States? |
No |
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c.)Fraud, deceit, or misconduct in the
establishment of or maintence of workers' compensation coverage? |
No |
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d.)Fraud, deceit, or misconduct in the
operation of a professional employer organization? |
No |
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e.)Found guilty by a court of competent
jurisdiction of conduct or practices which show that registrant is incompetent,
negligent, dishonest, or so untruthful that money, property, or investments
may not safely be entrusted to them? |
No |
| If yes, to any of the above questions please
enter brief description here: |
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| 2.) Has either the Registrant or any of
its proposed controlling persons been refused a license, registration,
or certification as a PEO, PEO Group, or controlling person, or renewal
thereof, in any jurisdiction or territory in the United States? |
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| 3.) Has either the Registrant or any of
its proposed controlling persons been involved in or owned an interest
in a PEO or PEO Group that has been adjudicated bankrupt, filed proceedings
under the Bankruptcy Act, or has otherwise closed due to insolvency? |
No |
| 4.) Are any of the licenses, registrations,
or certifications of the Registrant or any of its proposed controlling
persons currently under investigation or currently pending disciplinary
action in any jurisdiction or territory in the United States? |
No |
| 5.) Has the Registrant or any of its proposed
controlling persons ever failed to satisfy any tax liabilities? |
No |
| 6.) Has the Registrant or any of its proposed
controlling persons ever been cited, fined, convicted, or had actions taken
against it/them for failure to maintain evidence of workers' compensation
insurance coverage? |
No
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| 7.) Has the Registrant or any of its proposed
controlling persons ever been found liable for civil fraud, deceit, or
misconduct by any court in any jurisdiction or territory in the United
States? |
No
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| 8.) Is the Registrant delinquent, as of
the date of registration, with respect to any of its obligations of payroll,
payroll related taxes, workers' compensation insurance or employee benefits
in any jurisdiction or territory in the United States? |
No
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Alabama Operations - Office Information
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| Address of Office: |
Contact Person's Full Name: |
Telephone Number: |
E-Mail Address: |
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Alabama Client Companies
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Prior Operation in Alabama
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| Has the applicant commenced operations
in Alabama prior to this registration? |
no
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Insurance Benefits
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| Will you provide workers' compensation
insurance coverage to any leased employee in the State of Alabama? |
No |
| Are the premiums on the policy as of the
date of this registration paid in full? |
no |
| If the answer to the previous question
is NO, are the unpaid amounts in dispute with your insurance carrier? |
yes test |
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Financial Statements
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| Is this registrant requesting a waiver
of this financial statement requirement? |
no
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| Are there any quartly or interim financial
statements in existence? |
no |
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