- Certification of Compliance -
Minnesota Workers' Compensation Law
***********************************
Minnesota Statute, Section 176.182 requires every state and local
licensing agency to withhold the issuance or renewal of a license 
or permit to operate a business or engage in an activity in Minnesota
until the applicant presents acceptable evidence of compliance with the
workers' compensation insurance coverage requirement of MSS Chapter
176. The information required is: the name of the insurance company,
the policy number, and dates of coverage or the permit to self-insure.
This information will be collected by the licensing agency and retained
in their files.

This information is required by law, and licenses and permits to
operate a business may not be issued or renewed if it is not provided 
and/or is falsely reported. Furthermore, if this information is not
provided or falsely state, it may result in a $1,000 penalty assessed
against the applicant by the Commissioner of the Department of Labor and
Industry.

Insurance Company Name:_______________________________________________
(NOT the Insurance Agent)

Policy Number:________________________________________________________

Dates of Coverage:_____________________to_____________________________

(or)

I am not required to have workers' compensation liability coverage
because:

( ) I have no employees
( ) I am self insured (include permit to self-insure)
( ) I have no employees who are covered by the workers' compensation
    law (these include: Spouse, Parents, Children and certain farm
    employees)

I certify that the information provided above is accurate and complete
and that a valid workers' compensation policy will be kept in effect
at all times as required by law.

Name:_________________________________________________________________
     (last, first, middle)

Doing Business As:____________________________________________________
                  (business name if different than your name)

Business Address:_____________________________________________________

City, State, Zip:________________________________ Phone:______________

Signature:_______________________________________ Date:_______________

**********************************************************************

State of Minnesota
License Applicant Information

Under Minnesota Law (M.S. 270.72), the agency issuing you this license
is required to provide to the Minnesota Commissioner of Revenue your
Minnesota business tax identification number and the Social Security
number of each license applicant.

Under the Minnesota Government Data Practices Act and the Federal
Privacy Act of 1974, we must advise you that:

· This information may be used to deny the issuance, renewal or transfer
  of your license if you owe the Minnesota Department of Revenue
  delinquent taxes, penalties, or interest;
· The licensing agency will supply it only to the Minnesota Department
  of Revenue. However, under the Federal Exchange of Information Act,
  the Department of Revenue is allowed to supply this information to
  the Internal Revenue Service;
· Failing to supply this information may jeopardize or delay the
  issuance of your license or processing your renewal application.

Please full in the following information and return this form along
with your application to the agency issuing the license. Do not return
this form to the Department of Revenue.

______________________________________________________________________
Name of license being applied for and license number

______________________________________________________________________
Licensing Authority (name of city, county or state agency 
                     issuing licenses)

______________________________________________________________________
License renewal date

*********************

Personal Information

______________________________________________________________________
Applicant's Last Name     First Name & Initial      Social Security No.

______________________________________________________________________
Applicant's address		City		State		Zip	

*********************

Business Information (if applicable)

______________________________________________________________________
Business Name

______________________________________________________________________
Business Address		City		State		Zip

______________________________________________________________________
MN Tax ID Number			    Federal Tax ID Number

If a Minnesota tax identification number is not required, please
explain on the reverse side of this form.

______________________________________________________________________
Signature			Title				Date