State of California |
TALENT AGENCY LICENSE |
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Department of Industrial Relations |
APPLICATION |
Division of Labor Standards Enforcement |
17.Name, residence address and position of each person with responsibility and authority to manage the business:
18.Name, residence address and percentage of profit sharing of each person with profit sharing interest in the business (exclude bona fide employees on stated salaries:
19. Will the business of this talent agency be conducted in connection with any other business? |
Yes |
No |
If yes, indicate the kind of business and circumstances (use separate sheet if necessary): |
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20. Does the talent agency or any of the persons names in Items 11, 12 or 16 presently:
(a) Owe any unpaid wages? |
Yes |
No |
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(b) Have any unpaid outstanding judgments? |
Yes |
No |
If yes to either, indicate the kind of business and explain the circumstances (use separate sheet if necessary):
21. Have any of the persons listed in items 11, 12 or 16 ever been convicted1 of a crime, either misdemeanor or felony?
Yes No
If yes, indicate the name of the person, the date, the place and explain the circumstances for each crime (use separate sheet if necessary). Attach
documentation to indicate disposition.
22. Will the talent agency have sub-agents or any other employees? Yes No
If yes, complete Items 23, 24 and 25 below and attach a copy of the Workers Compensation Certificate of Insurance
23. Name of Workers’ Compensation Insurance carrier:
24. Policy Number: |
25. Period covered: |
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From: |
To: |
CERTIFICATION
I am/We are aware of and agree to comply with the provisions of Section 3700 of the Labor Code which requires every employer to be insured against liability for workers’ compensation.
I/We, under penalty of perjury, confirm that I/We will comply with Section 1700.53 of the Labor Code not later than June 30, 2019, and understand that the Labor Commissioner may at any time conduct an inspection to ensure compliance with Sections 1700.50 and 1700.51.
I/We agree to operate as a talent agency in compliance with the provisions of the California Labor Code and with the Rules and Regulations issued by the Labor Commissioner of the State of California.
I/We hereby certify, under penalty of perjury, that the foregoing statements are true and correct and that I am/we are aware of the fact that ANY
MATERIAL MISREPRESENTATION IS GROUNDS FOR DENIAL OR SUBSEQUENT REVOCATION OF A LICENSE.
Executed at 2 ______________________________________ California, this ______ day of _________________________, 20 _____
Signatures: (Individual owner, each partner or each LLC member must sign; if corporation, any authorized corporate officer may sign. He/She must show his/her title and submit a copy of Articles of Incorporation and Statement by Domestic Stock Corporation)
Printed name and title |
Signature |
Printed name and title |
Signature |
1The term “convicted” includes instances in which suspension of sentence was had and probation granted, and where expungement proceedings under Penal Code section 1203.4 and the following were undertaken.
2If place of execution is outside California, the foregoing statements must be sworn to before a notary public or other officer authorized to take oaths and affirmations.