
PLEASE CONTINUE TO PAGE 3. Page 2 of 3
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 Signature Date
__________________________________________________________________________________________________________
Authorized Representative’s Printed Name Date
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 ZIP
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. F
or 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.