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Employer Report Form (Renewal) PC-1 - Illinois
| Employer Report Form (Renewal) Form. This is a Illinois form and can be used in Human Rights Commission Statewide . |
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State of Illinois Illinois Department of Human Rights Legal Division, Public Contracts Unit Make payment to: ILLINOIS DEPARTMENT OF HUMAN RIGHTS MAIL TO: IDHR - FISCAL UNIT 100 W. RANDOLPH - SUITE 10-100 CHICAGO, ILLINOIS 60601 TELEPHONE: 312-814-2432 (TTY: 866-740-3953) Contact a Public Contracts Unit Representative IDHR.PublicContracts@Illinois.gov IDHR EMPLOYER REPORT FORM (PC-1): RENEWAL OF A CURRENT IDHR NUMBER Instructions: This form is to be used by an entity RENEWING an IDHR Eligibility number. IDHR Eligibility Numbers expire five years after the date of issue, and may be renewed at that time for an additional $75 fee. The information requested is necessary to accomplish the statutory purpose set forth in 775 ILCS 5/1-101 et seq. Disclosure of this information is REQUIRED. Forms received with employment data omitted will not be processed. The gathering and retention of employee race/ethnicity and gender data is permitted by state and federal law so long as such data are kept separate from other personnel information and are not used for the purpose of committing unlawful discrimination. For administrative details, review 44 Ill. Admin. Code, Section 750.210(a). You must file a renewal if your company wants to maintain eligibility to bid on state contracts and any one of the following applies: 1) your company employs 15 or more persons at the time of application for a public contract; 2) your company has employed 15 or more persons at any time during the 365 day period prior to the date of your applying for a public contract; 3) you are directed to file by a contracting agency of the State of Illinois, any political subdivision, or a municipal corporation. A form is deemed filed when it is received by the IDHR Chicago office, PROPERLY completed, signed, and accompanied by a certified check, money order, or cashier's check for $75 payable to the Illinois Department of Human Rights. No personal checks, business checks, or credit card numbers will be accepted. Any form without an approved form of payment will be returned unprocessed. This form must be filed prior to bid opening. Sexual Harassment Policy: NO company without a sexual harassment policy will be issued an IDHR number. If your organization has no policy, and would like a model for creating one, please visit: http://www2.illinois.gov/dhr/PublicContracts/Pages/Sexual_Harassment_Model_Policy.aspx. Federal Employer Identification Number (FEIN) must be provided. If your entity has multiple locations that all have the same FEIN, you are only obligated to pay one fee ($75) to receive an IDHR number for any locations having the same FEIN and wishing to be eligible to bid on business with the State of Illinois. The following form must be filled out for EACH location applying to do business with the State. Click here to open additional blank copies of the following form. (IDHR EMPLOYER REPORT FORM 1/31/2012) Instructions Page Keep for your records American LegalNet, Inc. www.FormsWorkFlow.com State of Illinois Illinois Department of Human Rights Legal Division, Public Contracts Unit Renewal Name of Applying Company: Address: City: Contact Name: Individual or sole proprietor Partnership Corporation - for profit JOB CATEGORIES Executive/Senior Level Officials First/Mid-Level Officials and Managers Professionals Technicians Sales Workers Administrative Support Workers Craft Workers Operatives Laborers and Helpers Services Workers TOTAL W State: ZIP: Make Payment ($75 Certified Check, Cashier's Check, or Money Order) to: ILLINOIS DEPARTMENT OF HUMAN RIGHTS and mail to: IDHR - FISCAL UNIT 100 W. RANDOLPH - SUITE 10-100 CHICAGO, ILLINOIS 60601 FEIN: Prev. IDHR Number: County: Email: OtherCountry: Phone: Corporation - not for profit Government entity Educational institution MALE B H A AI T W B FEMALE H A AI T TOTAL W=White (Not of Hispanic Origin; B=Black or African American; H=Hispanic or Latino, A=Asian or Pacific Islander, AI=American Indian or Alaskan Native; T=Total Sole proprietorship: one employee and that same employee is the owner; must fill in the above chart for the one person. DATE OF ABOVE DATA: NOTE: ANSWER EACH QUESTION BELOW WITH INFORMATION PERTAINING TO THE WORK FORCE REPORTED ABOVE. Describe the goods or services produced at or provided by the employer. Identify the geographical area from which the company draws its employees. Use city, county, metropolitan statistical area, or distance from location. What is the maximum number of employees working for the company during a 12-month period? What is the average number of persons employed by the company on a year-round basis? How many disabled persons are employed by the company? Yes Is the employer a federal contractor pursuant to federal executive order 11246? Does the company normally hire additional employees to perform contract work? Is the company minority owned? Is the company female owned? Does the company have a current written affirmative-action plan? Does the company have a current written sexual harassment policy? Within the past three years, has the company been declared ineligible for any public contract based on a finding of employment discrimination? If yes, attach a separate sheet fully explaining the situation. Is this form for a location which shares a FEIN with another location that is already registered with IDHR? I certify that the information provided in this report, and in any attachments thereto, is true and accurate to the best of my knowledge and belief. The employer filing this report agrees to conform with the requirements set forth in the Illinois Human Rights Act, 775 ILCS 5/1-101 et seq., and the rules and regulations of the Department of Human Rights. I am authorized to sign this form on behalf of the employer. No SIGNATURE DATE TYPED NAME AND TITLE TELEPHONE EMAIL (IDHR EMPLOYER REPORT FORM 1/31/2012) Employer Report Form Submit to IDHR with Payment Note: An Employer IDHR Eligibility Number Expires 5 years from the date of issue/renewal. RENEWAL American LegalNet, Inc. www.FormsWorkFlow.com State of Illinois Illinois Department of Human Rights Legal Division , Public Contracts Unit Definitions, Clauses and Policies Applicable to the IDHR Employer Report Form Keep for your Records Definition of employee - For purposes of this form, an "employee" is an individual performing services for remuneration for the employer. All fulltime and permanent part-time employees are to be reported. Forms received containing mathematic errors
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