The Texas Vtdlr Sls 017 form is an application used by businesses seeking a limited license for staff leasing services in Texas. This form collects essential information about the company, including ownership structure, employee assignments, and financial requirements. Completing this form accurately is crucial for compliance with state regulations and successful licensure.
The Texas VTDLR SLS 017 form is a critical document for businesses seeking to obtain a limited license for staff leasing services in Texas. This application requires essential information about the business, including its name, federal ID number, and ownership structure, whether it be a corporation, partnership, or LLC. Applicants must provide both physical and mailing addresses, along with contact details for a designated representative. A key aspect of the form is the requirement to demonstrate positive working capital, which necessitates the submission of an audited financial statement. This statement must adhere to specific guidelines, including showing a minimum amount of working capital based on the number of employees assigned in Texas. Additionally, the form includes questions about the company's operations within Texas, such as the number of employees and whether the company maintains an office in the state. To ensure compliance, applicants must also provide documentation from the Texas Secretary of State, proof of worker’s compensation insurance if applicable, and details about any other insurance coverage offered to employees. Completing this form accurately and thoroughly is essential, as any discrepancies or omissions can lead to delays or complications in the licensing process.
TEXAS DEPARTMENT OF LICENSING AND REGULATION
P. O. Box 12157 • Austin, Texas 78711 • (800) 803-9202 • Fax (512) 463-5984
E-mail: staff.leasing.services@license.state.tx.us Web site: www.license.state.tx.us
FEE
RECEIPT NUMBER
PMT.
MONEY
AMOUNT
TYPE
$900
DO NOT WRITE IN THE FEE AREA IMMEDIATELY ABOVE
Staff Leasing Services Application: New Limited License
Company Information
1.Name of Business to be Licensed :_________________________________________________________
DBA (if applicable):_______________________________________________________________________
2.Federal ID Number (FEIN):__________________________________________________________________
3.Please indicate the type of ownership for this company:
Corporate
Partnership
Individual
Limited Liability Company
4. Business Physical Address:________________________________________________________________
NUMBER AND STREET
__________________________________________________________________________________________________________
CITY
STATE
ZIP
5.Business Mailing Address: ________________________________________________________________
NUMBER AND STREET OR PO BOX
___________________________________________________________________________________________________________
6.Business Phone:__________________________________ 7. Business Fax:________________________
8.Please answer the following questions:
[ ] Yes [ ] No
Does this company employ fewer than 50 assigned employees in Texas at one time?
[
] Yes
]
No
Does this company assign employees to any client company based or domiciled in Texas?
Does this company solicit client companies located or domiciled in Texas?
Does this company maintain an office in Texas?
Is this company licensed or registered as a staff leasing services company in the state
where domiciled? (If yes, attach a copy of license or registration).
_____________
Number of employees assigned in Texas.
State where company is domiciled.
Contact Information
9.Contact person: _________________________________________________ Title:______________________
10.Contact e-mail:______________________________ 11. Contact phone:_____________________________
12.Texas Secretary of State Document - An application for a new license must include a copy of a document from the Texas Secretary of State that recognizes the business entity. This document must be issued in exactly the same business name as the applicant for this license and can be in the form of a Certificate of Authority or Certificate of Incorporation. Contact the Texas Secretary of State’s office at (512)463-5555 or at www.sos.state.tx.us for more information. Please enclose this document with your application.
YOU MUST COMPLETE ALL OF THE INFORMATION REQUESTED ON THIS FORM AND ALL OF THE REQUIRED ATTACHMENTS. PLEASE CONTINUE TO PAGE 2.
TDLR Form SLS 017 (12/2011)
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13. Working Capital Requirements
Pursuant to House Bill 2249 (81st Legislature, 2009) effective December 31, 2011, all Staff Leasing Services companies must submit an audited financial statement that shows positive working capital. Please enclose your most recent audited financial statement with this application.
“Working capital” of an applicant means the applicant’s current assets minus the applicant’s current liabilities as determined by generally accepted accounting principles. An applicant for an original or renewal license must demonstrate positive working capital in the following amounts:
(1)$50,000 if the applicant employs fewer than 250 assigned employees;
(2)$75,000 if the applicant employs at least 250 but not more than 750 assigned employees; and
(3)$100,000 if the applicant employs more than 750 assigned employees.
The audited financial statement must be prepared in accordance with generally accepted accounting principles, be audited by an independent certified public accountant, and be without qualification as to the going concern status of the applicant.
Please note: surety bonds, letters of credit, or guarantees ALONE are no longer accepted as proof of positive working capital. You MUST submit an audited financial statement for the company named on this application. Any deficiencies in the working capital requirement may be satisfied through guarantees, letters of credit, a surety bond or other security acceptable to TDLR, provided they are accompanied by the company’s audited financial statement. For more information on working capital requirements, please see our website: www.license.state.tx.us/sls/sls.htm or call us at (800) 803-9202.
14. Controlling Persons and/or Corporations
FORMS ARE AVAILABLE AT OUR WEBSITE: www.license.state.tx.us/sls/slsforms.htm
Please submit a Controlling Person Personal Information Form for each Controlling Person of your company.
Please submit a Controlling Corporation Information Form, if applicable.
15. Additional Attachments & Information
WORKER’S COMPENSATION CERTIFICATE OF INSURANCE: Please enclose a certificate of insurance if you offer worker’s comp insurance to employees assigned in Texas. Insurers must be authorized by Texas Dept. of Insurance. INSURANCE INFORMATION FORM: Please complete the enclosed Insurance Information Form (page 3) for all other types of insurance offered to employees assigned in Texas, if applicable. Do not submit certificates or booklets for other types of insurance (health, disability, life, etc.).
DESIGNATED AGENT FOR SERVICE: Please provide the following information for your agent for service in Texas:
________________________________________________________________(________)__________ - ___________
Agent Name
Agent Phone
_______________________________________________________________________________________________________TX_______________
Agent Address
City
16. Authorized Signature
I certify that I have read the Staff Leasing Services Act, Title 2, Labor Code, Subtitle E, and the current Department of Licensing and Regulation rules. If the license is issued, I agree to furnish to the Department of Licensing and Regulation any change in information on this form and all attached documents within FORTY-FIVE (45) DAYS of the change.
Licensure is subject to revocation if the department is not notified, in writing, of any changes in the information given on this application or if there is a rule or law violation.
I certify that all information submitted on this application and on all attached documents is true and correct.
Authorized Representative’s SignatureDate
Authorized Representative’s Printed Name
Date
PLEASE CONTINUE TO PAGE 3.
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17. Insurance Information Form
Please list all types of insurance coverage offered to employees assigned in Texas. Insurers must be authorized by the Texas Department of Insurance. If you offer worker’s comp insurance, please enclose the Certificate of Insurance in addition to listing it below. Do not submit any other type of certificate of insurance, booklet, or paperwork for any other type of insurance except worker’s comp.
Be advised that “self-insurance” health benefit plans are not allowed except as described in the Staff Leasing Services Labor Code:
Sec. 91.043. Health Benefit Plans.
(a)A license holder may not sponsor a plan of self insurance for health benefits except as permitted by the Employee Retirement Income Security Act of 1974 (29 U.S.C. Section 1001 et seq.).
(b)For purposes of this section, a "plan of self insurance" includes any arrangement except an arrangement under which an insurance carrier authorized to do business in this state has issued an insurance policy that covers all of the obligations of the health benefits plan.
If you are using any plan which is not fully insured, you will be required to submit an opinion from the U.S. Dept. of Labor that states your insurance plan is permitted by the Employee Retirement Income Security Act (ERISA).
Are you currently providing a plan which is NOT fully insured?
NO
YES
NAME OF INSURER
TYPE OF COVERAGE
EFF. DATE
EXP. DATE
POLICY NUMBER
__________________________________
_________________
_________
_____________________
Please submit this completed application, any attachments and the appropriate fees to the address at the top of page 1. For additional forms and information, please visit our website at: www.license.state.tx.us/sls/sls.htm
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