Disclosure Addendum {5380}

5380 - WORKER LEASING APPLICATION DISCLOSURE ADDENDUM FORMS 2466 AND 5364. This form is used by individuals or entities applying for a worker leasing license with the Oregon Workers’ Compensation Division to provide detailed information related to any “yes” responses on the license application. Specifically, this form must be completed for each affirmative answer given under the "Applicant Business History" or "Controlling Person Disclosures" sections. It ensures full transparency regarding past criminal, civil, administrative, or financial issues that may affect the applicant’s or controlling person’s eligibility for licensure. The form collects information such as case names and numbers, court jurisdictions, license or registration numbers, the nature and date of actions, and the current status or outcome. It also allows the applicant to submit additional documentation or explanations that may assist the division in evaluating the license request in accordance with OAR 436-180-0140. www.FormsWorkflow.com