ERD-12192-E, Employment Agent Registration
|State of Wisconsin |Employment Agents Registration |
|Department of Workforce Development | |
|Equal Rights Division | |
|Authorization for this form is provided under Chapter 105 Wisconsin Statutes and Section DWD 277.02 of Wisconsin Administrative Code. Use of this form is |
|mandatory. This information is used for the purpose of processing your application and maintaining the division’s records. Personal information you provide may |
|be used for secondary purposes [Privacy Law, s. 15.04(1) (m), Wisconsin Statutes] |
|Proposed Agency Name |Email Address |
| | |
|Street Address |
| |
| |
|City |State |Zip Code |Telephone Number |
| | | |( )- - |
|Mailing Address (if different from street address) |
| |
|City |State |Zip Code |
| | | |
|Type of Ownership |
|Corporation LLC Partnership Individual Proprietorship |
|List the names and home addresses of all stockholders, partners or owners. |
|Name |
| |
|Street Address |
| |
|City |State |Zip Code |Telephone Number |
| | | |( )- - |
|Name |
| |
|Street Address |
| |
|City |State |Zip Code |Telephone Number |
| | | |( )- - |
|Name |
| |
|Street Address |
| |
|City |State |Zip Code |Telephone Number |
| | | |( )- - |
|Does your agency engage in making home care placements? YES NO |
|A “home care placement” is the placement of any person in a private home to provide medical or companionship care for a consumer. It includes situations where the|
|consumer is employing the individual, the worker is self-employed or the worker is employed by a third party. |
|Veterans License Fee Waiver: To request waiver of the registration fee under the Veterans License Fee | |
|Waiver program, please provide the 8-digit code given to you by the Department of Veterans Affairs (the | |
|waiver is only available for first-time registrants): | |
|Enclose a $5.00 check for the registration fee made payable to the Equal Rights Division. |
|Call 608-266-6860 for assistance. |
| |
|Return the completed form & check to: |
| |
|EQUAL RIGHTS DIVISION PO BOX 8928 MADISON WI 53708 |
|Please staple check HERE to the bottom of the form. |
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