Worker Leasing Limited License Application {5362}

5362 - WORKER LEASING LICENSE APPLICATION – LIMITED. This form is used to apply for a limited worker leasing license through the Oregon Workers' Compensation Division. It is intended for out-of-state companies that lease workers to Oregon clients under specific conditions. To qualify, the applicant must be domiciled outside Oregon, have no Oregon location, and must not directly solicit Oregon-based clients. The company may serve no more than two clients in Oregon and may lease no more than five workers within the state. The form collects detailed applicant information, including legal and business names, contact details, licensing documentation from approved states, and client information specific to Oregon operations. The applicant must also submit signed tax release forms, safety training procedures, and proof of current licenses in designated states. An affidavit section requires the applicant to affirm the truthfulness and completeness of the application under penalty of perjury, and the form must be notarized before submission. Upon approval, a $2,050 fee is requested, and the license is valid for two years unless renewed. www.FormsWorkflow.com