Form Dlse 666 – Fill Out and Use This PDF

16. If corp oration or LLC - fu ll nam e, title, resid ential ad d ress, and social secu rity nu m ber of all corp orate officers/ LLC	17. H om e telep hone nu m ber
m em bers	of each p erson nam ed in item
N am e and title:_________________________________________________________________________________________________	16
H om e Ad d ress: ________________________________________________________________________________________________
Social Secu rity N u m ber: _________________________________________________________________________________________
N am e and title:_________________________________________________________________________________________________	(	) _________________
H om e Ad d ress:_________________________________________________________________________________________________
Social Secu rity N u m ber: _________________________________________________________________________________________
N am e: and title: ________________________________________________________________________________________________	(	) _________________
H om e Ad d ress: ________________________________________________________________________________________________
Social Secu rity N u m ber: _________________________________________________________________________________________
	(	) _________________
18. Fu ll nam e, resid ential ad d ress, and social secu rity nu m ber of all p ersons em p loyed by the ap p licant w ho exercise	19. H om e telep hone nu m ber
management responsibility over any car washing and polishing facility operated by applicant, regardless of applicant’s	of each p erson nam ed in item
form of legal entity	18
N am e: ________________________________________________________________________________________________________
H om e Ad d ress:_________________________________________________________________________________________________
Social Secu rity N u m ber: _________________________________________________________________________________________
N am e:_________________________________________________________________________________________________________	(	) _________________
H om e Ad d ress:_________________________________________________________________________________________________
Social Secu rity N u m ber _________________________________________________________________________________________
N am e:_________________________________________________________________________________________________________	(	) _________________
H om e Ad d ress:_________________________________________________________________________________________________
Social Secu rity N u m ber: _________________________________________________________________________________________
N am e:_________________________________________________________________________________________________________	(	) _________________
H om e Ad d ress:_________________________________________________________________________________________________
Social Secu rity N u m ber: _________________________________________________________________________________________
	(	) _________________
20. Fu ll nam e, resid ential ad d ress, and social secu rity nu m ber of all p ersons, excep t bona fid e em p loyees on regu lar salaries ,	21. H om e telep hone nu m ber
who have a financial interest of 10 percent or more in applicant’s business, regardless of applicant’s form of legal entity.	of each p erson nam ed in item
A) N am e:______________________________________________________________________________________________________	20
H om e Ad d ress:_________________________________________________________________________________________________
Social Secu rity N u m ber: _________________________________________________________________________________________
B) N am e: ______________________________________________________________________________________________________	(	) _________________
H om e Ad d ress:_________________________________________________________________________________________________
Social Secu rity N u m ber: _________________________________________________________________________________________
C) N am e:	(	) _________________
______________________________________________________________________________________________________
H om e Ad d ress:_________________________________________________________________________________________________
Social Secu rity N u m ber: _________________________________________________________________________________________	(	) _________________
D) N am e:
______________________________________________________________________________________________________
H om e Ad d ress:_________________________________________________________________________________________________	(	) _________________
Social Secu rity N u m ber: _________________________________________________________________________________________

DLSE 666 (09/05) (English)

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27. Does any p erson nam ed in item s 12, 14, 16, 18, or 20 p resently:
A. Ow e an em ployee any unpaid wages?...……………………………………………………………...…..Yes	 N o
B. Have an unpaid judgment outstanding? ………………………………………………………………....Yes	 N o
C. Have an outstanding lien or lawsuit pending against him/ her?..……………………………………..Yes	 N o
D. Ow e payroll taxes, p ersonal, p artnership or corp orate incom e taxes, social secu rity taxes
or disability insurance contributions?……………………………………………………………..……...Yes	 N o

If “yes” to any of the above, provide details below, including name, ad d ress and telep hone nu m ber of the em p loyee(s), ju d gm ent cred itor(s),

lienhold er(s), other party(ies) to the law su it, and / or governm ental agency that is ow ed m oney, case/ file nu m ber, a d escrip tio n of the type of d ebt, tax, lien, or law su it, am ou nt ow ed , cou rt w here the law su it is p end ing, and a d escrip tion of any paym ent arrangem ents, if any.

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28. H as a bu siness nam ed in item s 1 or 6, or a p erson nam ed in item s 12, 14, 16, 18, or 20, ever been cited or assess ed a p enalty for violating a p rovision of the

California Labor Cod e, or an ord er of the Ind u strial Welfare Com m ission regu lating w ages, hou rs and w orking cond itions?  Yes

 N o

If “yes,” provide details below, including, name of the busin ess/ p erson cited , d ate and natu re of citation, am ou nt of p enalties assessed for each citation, and the d isp osition of the citation, if any. Describe any ap p eal filed contesting the citation, and the ou tcom e. If the citatio n w as not ap p ealed , or if it w as

ap p ealed and u p held , ind icate w hether or not the p enalty assessm ent w as p aid , and if so, the d ate on w hich it w as paid .

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29. Does ap p licant have any final ju d gm ents against him , her, or it for u np aid w ages d u e an em p loyee or form er em p loyee of a car w ashing and p olishing

bu siness that is requ ired to be registered p u rsu ant to California law that has not been fu lly satisfied ?

 Yes

 N o

If, ”yes,” provide details below, including, name of pa rties, nam e and location of cou rt and case nu m ber, am ou nt of ju d gm ent, d ate ju d gm ent becam e final, and an exp lanation as to w hy ju d gm ent has not been fu lly satisfied .

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30. H as ap p licant rem itted the p rop er am ou nt of contribu tions required by the California Unem p loym ent Insu rance Cod e?			 Yes	 N o
If “no,” has the Employment Development Department (EDD) made an assessment for those unpaid contributions that has become fi nal?				Yes  N o
If “yes,” has the amount of delinquency been paid in full?	 Yes	 N o

If “yes,” provide the amount of the delinquency and the date it was paid in full. $______________________________Date________________________________

If “no,” describe the nature and amount of delinquency, and explain why it has not been paid in full.

____________________________________________________________________________________________________________________________________________

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31. H as ap p licant rem itted the fu ll am ou nt of Social Secu rity and Med icare tax contribu tions requ ired by the Fed eral Insu ran ce Contribu tions Act (FICA) to

the Internal Revenu e Service (IRS)?	 Yes	 N o
If “no,” has applicant fully paid the amount or delinquency for those unpaid contributions?			 Yes	 N o

If “no,” explain why the full amoun t of contribu tions w as not rem itted to the IRS, and w hy the d elinqu ency has not been paid in fu ll.

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DLSE 666 (09/05) (English)

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Ap p licant hereby acknow led ges that he/ she/ it is aw are of and agrees to com p ly w ith the p rovisions of Labor Cod e Section 3700 that requ ires every em p loyer to secure the payment of compensation for liability under the State’s worker compensations law . Applicant hereby submits pro of that the p aym ent of compensation for liability under the State’s workers’ compensation law has been se cu red in a law fu l m anner.

Applicant understands and acknow ledges that any misrepresentation, falsification, or material omission on this application or any document submitted in connection herew ith is a ground for denial of this application or subsequent revocation of registration.

Ap p licant hereby agrees to com p lete and su bm it to the IRS an IRS Form 8821, Tax Inform ation Authorization .

The undersigned hereby certify(ies) under penalty of perjury that the statements made and information provided on this application are true and correct and that the applicant is in complete compliance with the local government’s business licensing and regional regulatory

requirements.

Execu ted at *_____________________________________, California, this ______________ d ay of ______________________________, 2 __________.

SIGN ATURES (Th e ind ivid ual ow ner or all general p artners m u st sign . If bu siness is a corp oration or lim ited liability com p any, any auth orized corporate officer or m em ber m ay sign .)

____________________________________________________ _________________________________________________________

____________________________________________________ _________________________________________________________

*If 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.

SOCIAL SECURITY N UMBER COLLECTION

Th e social secu rity nu m ber w ill be collected p u rsu ant to California Fam ily Cod e section 17520(d ) and Labor Cod e section 2061(a)(6). It is u sed in the administration of registering employer’s in the car washing and polishing industry, and to aid in the collection of monies ow ed p u rsu ant to a ju d gm ent or

ord er for child or fam ily su p p ort in a case being enforced u nd er Title IV-D of the Social Secu rity Act.

Collection of the social security number is mandatory. Failure to furnish the social security number may result in D EN IAL of an application for issuance or renew al of a registration to engage i n the business of car w ashing and polishing.

IN FORMATION PRACTICES ACT N OTICE (California Civil Code Section 1798.17)

1. Th e inform ation on this ap p lication is being requ ested by the Dep artm ent of Ind u strial Relations, Division of Labor Stand ard s En forcem ent.

2. Th e state official resp onsible for m aintaining this ap p lication, and w ho shall, u p on w ritten requ est, inform you of the l ocation of w here this ap p lication is m aintained and the categories of any p ersons w ho u se the inform ation contained herein is:

Manager, Licensing and Registration Unit

Division of Labor Stand ard s En forcem ent, 9th Floor West P.O . Box 420603

San Francisco, CA 94142

Telep hone: (415) 703-4810

3.Th e inform ation on this ap p lication is collected and m aintained pu rsu ant to C alifornia Labor Cod e section 2061.

4.With resp ect to the inform ation requ ested on this ap p lication, all of it is either m and ated by California Labor Cod e sect ion 2061 or m ust be ascertained by the Labor Com m issioner in ord er to issu e a registration, exce p t for the follow ing inform ation, w hich is p rovid ed volu ntarily:

A) Title of corp orate officers/ LLC m em bers

5. If you fail to p rovid e all or any p art of the inform ation requ ested in this ap p lication, the Labor Com m issioner m ay d eny issu ance/ renew al of a registration to engage in the bu siness of car w ashing and polishing.

6.Th e p rincip al p u rp oses w ithin the Division of Labor Stand ard s Enforcem ent for w hich the inform ation on this ap p lication w ill be u sed are: (1) ad m inistration of the registration p rogra m for the car washing and polishing industry, and (2) enforcement of California’s labor laws.

7.Th e follow ing are know n or foreseeable d isclosu res of the inform ation contained herein w hich m ay be m ad e p u rsu ant to su bd ivision (e) or (f) of Section 1798.24 of the California Civil Cod e by the Division of Labor Stand ard s En forcem ent: Resp onse to a requ est u nd er the California Pu blic Record s Act.

8.You have the right to access record s containing you r p ersonal inform ation that are m aintained by the Division of Labor Stand ard s Enforcem ent. To m ake an ap p ointm ent to access su ch record s, p lease contact the Manager, Licensing and Registration Unit at the ad d ress show n in it em 2 above.

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D O N OT WRITE BELOW THIS LIN E

 WCI _______________	 Articles of Incorporation
Date	 LLC Articles of Organization
 IRS ________________	 Business License/Regional Regulatory Requirements
Date Cleared	 Leased Employee Agreement
 Bond	 FBN
 I.D .	 Citation(s)/Judgment(s) _______________
 SOS _______________	Date
D ate

DLSE 666 (09/05) (English)

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