EMPLOYEE LEASING ACT

EMPLOYEE LEASING CONTRACTOR REGISTRATION APPLICATION

EMPLOYEE LEASING CONTRACTOR REGISTRATION APPLICATION

  • An incomplete applicationwill not be processed and will be returned to the applicant with a notice indicating the deficiencies.
  • The name of the businessentity or the DBA must be EXACTLY THE SAME on all attachments. If the names differ in any respect, the application will not be processed and will be returned to the applicant.
  • Any change in the informationprovided in the original application packet will subject a registration to cancellation unless reported to the Employee Leasing Program, in writing, within 30 days of the effective date of the change.
  • Registration/certification under the Employee Leasing Act is NON-TRANSFERABLE. Any change in the name of the company requires NEW registration under the new name.
  • The bond or assignment of cash collateral must remain in place for the duration of the registration. Cancellation of the bond or the collateral assignment will subject the registration to cancellation.
  • A certificate issued pursuant to the Employee Leasing Act is valid (unless revoked or suspended) for twelve months from the date of issuance. Failure to renewbefore the expiration of a certificate will result in the assessment of a $500 late fee and may subject the registration to cancellation.
COMPLETE THE APPLICABLE SECTIONS
  • If sole proprietorship, complete Sections A, C, E and the Verification.
  • If a partnership, complete Sections A, D, E and the Verification.
  • If a business entity other than a sole proprietorship or partnership, complete Sections A, B, E and the Verification.
SUBMIT THESE DOCUMENTS WITH THE COMPLETED APPLICATION FORM
  • Documentation authorizing the entity to do business in New Mexico: If applicant is a business entity (not a sole proprietorship), a copy of the applicable documentation authorizing the entity to do business in New Mexico is required. For assistance in determining the required documentation, contact the New Mexico Public Regulation Commission by consulting their website at or by phone at 888-ASKPRC (427-5772). Generally the following documents are required:
Domestic corporation / Certificate of Incorporation
Foreign corporation / Certificate of Authority
Domestic limited liability company / Certificate of Organization
Foreign limited liability company / Certificate of Registration
Partnership (general and limited) / Certificate of Registration (issued by NM Secretary of State)
  • Attachment 1 - STATEMENT OF AUTHORIZATION AGENT FOR SERVICE OF PROCESS: Notarized statement signed by individual authorized to bind the agent for service of process in New Mexico for the applicant company.
  • EITHERAttachment 2 - a surety bond in the amount of $100,000 on the form provided ORAttachment 3 - an assignment of cash collateral on the form provided.
  • Copy of an insurance certificate showing compliance with the New Mexico Workers Compensation Act,NMSA 1978, Section 52-1-4. In order to complete this registration, the applicant must have a WORKERS COMPENSATION number and the Certificate of Insurance MUST be attached. Coverage must be current.
TAX AND INSURANCE NUMBERS
Each applicant must provide the following numbers:
  • New Mexico Tax CRS-1 Identification Number. For assistance, contact the New Mexico Taxation and Revenue Department by e-mail at or phone 505-841-6200.
  • New Mexico Workers’ Unemployment Insurance Number. For assistance, contact the New Mexico Department of Work Force Solutions by e-mail ()or phone 505-841-8576.
  • New Mexico Workers’ Compensation Number. For assistance, contact the New Mexico Workers’ Compensation Administration by phone, 505-841-6000.

APPLICATION FEE
Theregistration fee is $1,000. Submit payment with this application by check or money order payable to Employee Leasing Program. Credit cards are not accepted. Do not mail cash.
This form can be filled in using your computer. Enter information in the gray boxes and tab from box to box to move through the application. If you prefer to fill it in using a pen, be sure to print legibly.
Date of Application:
A. TYPE OF ENTITY: check only the box that applies to the business entity type of the applicant.
Domestic CorporationForeign Corporation Partnership Sole Proprietor
Domestic LLCForeign LLC Limited Partnership
B. For BUSINESS ENTITY OTHER THAN A SOLE PROPRIETOR, complete this section:
1. Name of company to be licensed:
2. Street address of principal place of business:
City: / County: / State: / Zip:
3. Mailing Address (if different):
Business phone: / Fax: / E-mail:
MailingCity: / MailingState: / Mailing Zip:
4. Point of contact: / Title or position:
Yes No -- Has this company been licensed as a New Mexico construction contractor? If yes:
Licensee name: / License number:
Date issued: / Yes No – Has this license been revoked?
C. If applicant is a SOLE PROPRIETOR/INDIVIDUAL, complete this section.
Name: / DBA:
SSN: / D.O.B. / Place of birth (city/state):
Residence street address:
City: / State: / Zip:
Business street/P.O. Box address, if different:
BusinessCity: / BusinessState: / Business Zip:
Business phone: / Fax:
Residence phone: / E-mail:
Yes No – Has this individual previously been certified as a New Mexico as a qualifying party for a licensed construction contractor? If yes:
Certificate number: / Date issued: / Yes No – Has this certificate been revoked?
D. For a GENERAL OR LIMITED PARTNERSHIP, provide the following information for each general partner. Use additional pages, if necessary.
Name:
SSN: / D.O.B. / Place of birth (city/state):
Street address:
City: / State: / Zip:
Partnership address of business:
Business phone: / Fax: / E-mail:
Contact: / Title or position:
Name:
SSN: / D.O.B. / Place of birth (city/state):
Street address:
City: / State: / Zip:
Partnership address of business:
Business phone: / Fax: / E-mail:
Contact: / Title or position:
Name:
SSN: / D.O.B. / Place of birth (city/state):
Street address:
City: / State: / Zip:
Partnership address of business:
Business phone: / Fax: / E-mail:
Contact: / Title or position:
E: ALL APPLICANTS MUST COMPLETE THIS SECTION.
Yes No / 6. Has any bonding or surety company ever completed or made a settlement in which you were involved? If yes, attach details of settlement on separate page.
REQUIRED NEW MEXICO TAX AND INSURANCE NUMBERS
Workers’ Compensation Identification number:
New Mexico CRS-1 number:
Federal Tax ID number:
Unemployment Insurance number:
Name of registered agent for service of process in New Mexico:
Registered agent street address:
City: / State: / Zip:

This application must be signed and dated in the presence of a Notary Public.

VERIFICATION
By signing this application, the undersigned attests that all information provided in the application is true, to the best of the signatory’s knowledge; he/she is authorized to bind the applicant company; the applicant warrants that he/she/it will provide all benefits required by law to be provided by employers to employees; and shall abide by all laws applicable to employee leasing companies in the State of New Mexico, including without limitation, the Employee Leasing Act, NMSA 1978, Section 60-13A-1, et seq., and all rules promulgated pursuant thereto.
Print name of applicant of DBA of sole proprietor: / Title:
Applicant signature: / Date:
NOTARIZATION
On this ______day of ______, 20 ____, ______appeared before me, who is personally known to me to be the person described in this application and the person whose signature appears on this application; he/she swore under penalty of perjury that all information provided in this application is true and correct to the best of his/her knowledge and acknowledged that this instrument was executed as his/her free act and deed.
Notary Public:
My Commission Expires:

This statement of authorization must be signed and dated in the presence of a Notary Public.

ATTACHMENT 1 - STATEMENT OF AUTHORIZATION AGENT FOR SERVICE OF PROCESS
Name of agent:
Street address:
City: / State: / Zip:
The aforenamed agent hereby acknowledges that: the agent accepts and agrees to act as the registered agent for service of process in New Mexico for ______, an employee leasing company registered to do business in New Mexico, pursuant to the Employee Leasing Act, NMSA 1978 Section 60-13A-1, et seq., effective as of ______, 20___; and that the agent is duly authorized to do business in New Mexico.
Signature: / Date:
NOTARIZATION
On this ______day of ______, 20 ____, ______, appeared before me, who is personally known to me to be the person who executed this Statement of Authorization.
Notary Public:
My Commission Expires:
ATTACHMENT 2 - SURETY BOND
Bond number: / Employee Leasing number:
KNOW ALL MEN BY THESE PRESENTS: that (company name) ______,
as Principal, the principal place of business of which is______, and ______as Surety, are held and firmly bound unto the State of New Mexico, Regulation and Licensing Department, as Obligee, in the penal sum of One Hundred Thousand Dollars and No Cents ($100,000.00) lawful money of the United States, for the payment of which, well and truly to be made, we bind ourselves, our heirs, executors and administrators, successors and assigns, jointly and severably and firmly by these presents.
Effective: ______, 20___
WHEREAS, the above-bounden Principal has applied for registration to operate as an employee leasing company with the State of New Mexico.
NOW, THEREFORE, the condition of the obligation is such that if the above-bounden Principal shall comply with the applicable statutes of the State of New Mexico and all rules and orders of the Regulation and Licensing Department applicable to Employee Leasing Companies, then the above obligation shall be void; otherwise, to be and remain in full force and effect.
It is understood and agreed that: the aggregate liability of Surety shall not exceed the penal sum of this bond; this bond is continuous in form: and, if the Surety shall so elect, this bond may be cancelled thirty (30) days from the date of receipt of written notice of such cancellation from Surety to the Employee Leasing Program of the Regulation and Licensing Department of the State of New Mexico.
Signature and Title for Principal:
Name and Address of Local Agency Issuing Bond:
Bonding Company:
Bonding Agent:
BONDING COMPANY MUST BE AUTHORIZED TO DO BUSINESS IN NEW MEXICO
AND POWER OF ATTORNEY MUST BE ATTACHED

ATTACHMENT 3 - ASSIGNMENT OF CASH COLLATERAL DEPOSIT

This form must be signed and dated in the presence of a Notary Public.

Pursuant to Section 7 B. of the New Mexico Employee Leasing Act, NMSA 1978,Section 60-13A-1 et seq., ______(Employee Leasing Contractor ) has deposited with ______(Financial Institution), the principal place of business of which is located at ______,

Address State Zip Phone

and which is duly authorized to do business as such in the State of New Mexico, the sum of One Hundred Thousand Dollars ($ 100,000.00) in savings account number ______(Fund).

Employee Leasing Contractor hereby assigns and conveys all right, title and interest in the deposited fund sum to the Financial Institution in trust for the Regulation and Licensing Department (Department), or successor agency of the State of New Mexico. Employee Leasing Contractor and the Financial Institution agree as follows with respect to the deposited Fund:

  1. The Regulation and Licensing Department acquires by this assignment the entire beneficial interest in the Fund, with the right to order the trustee, in writing, to distribute the Fund or a portion thereof to persons determined by the Department to be entitled thereto in amounts determined by the Department pursuant to the New Mexico Employee Leasing Act.
  2. The Employee Leasing Contractor retains no legal or beneficial interest in the Fund and has only the statutory right to interest, if any, thereon, and to return of the Fund upon written order of the Department.
  3. The Financial Institution agrees that the Fund may be assigned, transferred, pledged or distributed only upon written order of the Department or a court of competent jurisdiction made in a proceeding in which the Department is a party. The financial Institution waives all statutory or common law liens or rights of set-off against the fund.
  4. The Financial Institution may deduct from interest due Employee Leasing Contractor, if any, attorney fees incurred by the Financial Institution as a result of responding to a claim or demand upon the Financial Institutions via wit, summons or other process arising out of the operation of the Employee Leasing Contractor’s business.

______

Signature of Employee Leasing Contractor Signature of Officer of Financial Institution

(Corporate Officer, Owner or Partner)

______

Title Phone #

NOTARIZATION

SUBSCRIBED AND SWORN TO BEFORE ME THIS ______DAY OF ______20_____.

Notary Public:

My commission expires:

Employee Leasing Act ApplicationRegistration

Rev. 11-2011Page 1 of 7