CAR WASHING AND POLISHING REGISTRATION APPLICATION

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State of California
Department Of Industrial Relations
DIVISION OF LABOR STANDARDS ENFORCEMENT

CAR WASHING AND POLISHING REGISTRATION APPLICATION

(If additional space is needed, please attach a separate page and indicate the number of the item for which the information is being provided.)

1. Nam e of legal entity (em ployer) applyin g for registration 2. Fictitious business nam e (d oing business as (d ba)), if applicable

3. Applicant’s street ad d ress (num ber, street, city, county, state, zip cod e) 4. Telephone num ber
5. Applicant’s mailing ad d ress, if d ifferent from street ad d ress (e.g., P.O. Box) ( ) __________________

6. Fictitious business nam e (d ba) and street ad d ress (num ber, street, city, county, state, zip cod e) of all car washing and 7. Telephone num ber of
polishing facilities operated by applicant: location listed in item 6
A) Dba: ( ) _________________
________________________________________________________________________________________________________
Ad d ress: ( ) _________________
_______________________________________________________________________________________________________
B) Dba: ( ) _________________
________________________________________________________________________________________________________
Ad d ress: ( ) _________________
_______________________________________________________________________________________________________
C) Dba:
________________________________________________________________________________________________________
Ad d ress:
_______________________________________________________________________________________________________
D) Dba:
________________________________________________________________________________________________________
Ad d ress:
_______________________________________________________________________________________________________

8. This is an application for 9. Is applicant perm issively self-insured against liability to pay workers’ com pensation 10. If renewal, give previous
a: claim s?  Yes  No registration number
 New Registration
If the answ er to th e above is “no,” d oes applicant have current workers' com pensation CW - ___________________
 Renewal Registration insurance coverage?  Yes  N o

N am e of Insurer: __________________________________________________________________
Ad d ress::_________________________________________________________________________
Policy N o ________________________________________________________________________
Effective date _________________________ Expiration d ate__________________________

11. Applicant’s form of legal entity (check one):

 Sole Proprietorship (an ind ivid ual)  Partnership  Corporation  Lim ited Liability Com pany
13. H om e telephone num ber
12. If sole proprietorship - full nam e, resid ential ad d ress and social security num ber of ow ner

N am e: ( ) _________________
_________________________________________________________________________________________________________

Home Address:
_________________________________________________________________________________________________

Social Security
N um ber:__________________________________________________________________________________________

14. If partnership - full nam e, resid ential ad d ress, and social security num ber of all partners 15. H om e telephone num ber
N am e: ________________________________________________________________________________________________________ of each person named in item
H om e Ad d ress: ________________________________________________________________________________________________ 14
Social Security N um ber:_________________________________________________________________________________________ ( ) _________________
N am e: ________________________________________________________________________________________________________
H om e Ad d ress: ________________________________________________________________________________________________ ( ) _________________
Social Security N um ber:_________________________________________________________________________________________
N am e: ________________________________________________________________________________________________________ ( ) _________________
H om e Ad d ress: ________________________________________________________________________________________________
Social Security N um ber: _________________________________________________________________________________________

DLSE 666 (09/05) (English) 1

16. If corporation or LLC - full nam e, title, resid ential add ress, and social security num ber of all corporate officers/ LLC 17. H om e telephone num ber
members of each person named in item
16
N am e and title:_________________________________________________________________________________________________
H om e Ad d ress: ________________________________________________________________________________________________ ( ) _________________
Social Security N um ber: _________________________________________________________________________________________
N am e and title:_________________________________________________________________________________________________ ( ) _________________
H om e Ad d ress:_________________________________________________________________________________________________
Social Security N um ber: _________________________________________________________________________________________ ( ) _________________
N am e: and title: ________________________________________________________________________________________________
H om e Ad d ress: ________________________________________________________________________________________________
Social Security N um ber: _________________________________________________________________________________________

18. Full nam e, resid ential ad d ress, and social security num ber of all persons em ployed by the applicant w ho exercise 19. H om e telephone num ber
m anagem ent responsibility over any car washing and polishing facility operated by applicant, regard less of applicant’s of each person named in item
form of legal entity 18

N am e: ________________________________________________________________________________________________________ ( ) _________________
H om e Ad d ress:_________________________________________________________________________________________________
Social Security N um ber: _________________________________________________________________________________________ ( ) _________________
N am e:_________________________________________________________________________________________________________
H om e Ad d ress:_________________________________________________________________________________________________ ( ) _________________
Social Security N um ber _________________________________________________________________________________________
N am e:_________________________________________________________________________________________________________ ( ) _________________
H om e Ad d ress:_________________________________________________________________________________________________
Social Security N um ber: _________________________________________________________________________________________
N am e:_________________________________________________________________________________________________________
H om e Ad d ress:_________________________________________________________________________________________________
Social Security N um ber: _________________________________________________________________________________________

20. Full nam e, resid ential ad d ress, and social security num ber of all persons, except bona fid e em ployees on regular salaries , 21. H om e telephone num ber
w ho have a financial interest of 10 percent or m ore in applicant’s business, regard less of applicant’s form of legal entity. of each person named in item
20
A) Nam e:______________________________________________________________________________________________________
H om e Ad d ress:_________________________________________________________________________________________________ ( ) _________________
Social Security N um ber: _________________________________________________________________________________________
B) Nam e: ______________________________________________________________________________________________________ ( ) _________________
H om e Ad d ress:_________________________________________________________________________________________________
Social Security N um ber: _________________________________________________________________________________________ ( ) _________________
C) Name:
______________________________________________________________________________________________________ ( ) _________________
H om e Ad d ress:_________________________________________________________________________________________________
Social Security N um ber: _________________________________________________________________________________________
D) Name:
______________________________________________________________________________________________________
H om e Ad d ress:_________________________________________________________________________________________________
Social Security N um ber: _________________________________________________________________________________________

22. Actual percent ow ned by each 23. If a corporation: 24. Fed eral and state 25. If a foreign corporation, 26. If a corporation, is
person nam ed in item 20. Date of incorporation: em ployer id entification d ate articles of incorporation corporation in good
A)____________________ _____________________________ numbers w ere filed w ith the California stand ing w ith the
B)____________________ Secretary of State California Secretary of
C)____________________ State of incorporation: FEIN: ________________ State?
D)____________________ _____________________________ _________________________  Yes
SEIN: ________________
 No

DLSE 666 (09/05) (English) 2

27. Does any person nam ed in item s 12, 14, 16, 18, or 20 presently:  No
A. Ow e an em ployee any unpaid w ages?...……………………………………………………………...…..Yes  No
B. Have an unpaid jud gm ent outstand ing? ……………………………………………………………….... Yes  No
C. Have an outstand ing lien or law suit pend ing against him/ her?..…………………………………….. Yes
 No
D. Ow e payroll taxes, personal, partnership or corporate income taxes, social security taxes
or d isability insurance contributions?……………………………………………………………..……...Yes

If “yes” to any of the above, provid e d etails below , includ ing nam e, ad d ress and telephone num ber of the em ployee(s), jud gm ent cred itor(s),
lienhold er(s), other party(ies) to the law suit, and/ or governm ental agency that is ow ed money, case/ file num ber, a d escriptio n of the type of d ebt, tax,
lien, or law suit, amount ow ed , court w here the law suit is pend ing, and a d escription of any payment arrangements, if any.

_______________________________________________________________________________________________________________________________________

_______________________________________________________________________________________________________________________________________

_______________________________________________________________________________________________________________________________________

_______________________________________________________________________________________________________________________________________

28. H as a business nam ed in item s 1 or 6, or a person nam ed in item s 12, 14, 16, 18, or 20, ever been cited or assess ed a penalty for violating a provision of the
California Labor Cod e, or an ord er of the Ind ustrial Welfare Com m ission regulating wages, hours and w orking cond itions?  Yes  No

If “yes,” provid e details below, includ ing, nam e of the busin ess/ person cited , d ate and nature of citation, am ount of penalties assessed for each citation, and
the d isposition of the citation, if any. Describe any appeal filed contesting the citation, and the outcom e. If the citatio n was not appealed , or if it was
appealed and upheld , ind icate w hether or not the penalty assessment was paid, and if so, the date on w hich it w as paid .

_______________________________________________________________________________________________________________________________________

_______________________________________________________________________________________________________________________________________

_______________________________________________________________________________________________________________________________________

_______________________________________________________________________________________________________________________________________

29. Does applicant have any final jud gm ents against him , her, or it for unpaid w ages d ue an em ployee or form er em ployee of a car washing and polishing

business that is required to be registered pursuant to California law that has not been fully satisfied ?  Yes  No

If, ”yes,” provid e d etails below , includ ing, name of pa rties, nam e and location of court and case number, amount of jud gm ent, date jud gm ent becam e
final, and an explanation as to w hy jud gm ent has not been fully satisfied .

_______________________________________________________________________________________________________________________________________

_______________________________________________________________________________________________________________________________________

_______________________________________________________________________________________________________________________________________

_______________________________________________________________________________________________________________________________________

30. Has applicant rem itted the proper am ount of contributions required by the California Unem ployment Insurance Cod e?  Yes  No

If “no,” has the Em ploym ent Developm ent Departm ent (EDD) mad e an assessm ent for those unpaid contributions that has becom e fi nal?  Yes  No

If “yes,” has the amount of d elinquency been paid in full?  Yes  No

If “yes,” provid e the am ount of the d elinquency and the date it was paid in full. $______________________________Date________________________________

If “no,” d escribe the nature and am ount of d elinquency, and explain w hy it has not been paid in full.

____________________________________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________________

31. Has applicant rem itted the full amount of Social Security and Med icare tax contributions required by the Fed eral Insuran ce Contributions Act (FICA) to

the Internal Revenue Service (IRS)?  Yes  No

If “no,” has applicant fully paid the amount or d elinquency for those unpaid contributions?  Yes  No

If “no,” explain w hy the full amoun t of contributions was not rem itted to the IRS, and w hy the d elinquency has not been paid in full.

____________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________

DLSE 666 (09/05) (English) 3

Applicant hereby acknow led ges that he/ she/ it is aware of and agrees to com ply w ith the provisions of Labor Cod e Section 3700 that requires every em ployer
to secure the paym ent of com pensation for liability und er the State’s w orker com pensations law . Applicant hereby subm its pro of that the paym ent of
com pensation for liability und er the State’s w orkers’ com pensation law has been se cured in a law ful manner.

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.

Applicant hereby agrees to com plete and subm 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 w ith the local government’s business licensing and regional regulatory
requirements.

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

SIGN ATURES (The ind ivid ual owner or all general partners m ust sign. If business is a corporation or lim ited liability com pany, 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

The social security num ber w ill be collected pursuant to California Fam ily Cod e section 17520(d ) and Labor Cod e section 2061(a)(6). It is used in the
ad m inistration of registering em ployer’s in the car washing and polishing ind ustry, and to aid in the collection of monies ow ed pursuant to a jud gm ent or

ord er for child or fam ily support in a case being enforced und er Title IV-D of the Social Security 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 renewal of a registration to engage in the business of car washing and polishing.

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

1. The inform ation on this application is being requested by the Departm ent of Ind ustrial Relations, Division of Labor Stand ard s Enforcem ent.
2. The state official responsible for m aintaining this application, and w ho shall, upon w ritten request, inform you of the l ocation of where this application is
m aintained and the categories of any persons w ho use the information contained herein is:

Manager, Licensing and Registration Unit
Division of Labor Standard s Enforcem ent, 9th Floor West
P.O. Box 420603
San Francisco, CA 94142

Telephone: (415) 703-4810
3. The inform ation on this application is collected and m aintained pursuant to C alifornia Labor Cod e section 2061.
4. With respect to the information requested on this application, all of it is either mandated by California Labor Cod e sect ion 2061 or m ust be ascertained by
the Labor Com m issioner in ord er to issue a registration, except for the follow ing information, which is provid ed voluntarily:

A) Title of corporate officers/ LLC m em bers
5. If you fail to provid e all or any part of the inform ation requested in this application, the Labor Comm issioner m ay d eny issuance/ renew al of a registration
to engage in the business of car washing and polishing.
6. The principal purposes w ithin the Division of Labor Stand ard s Enforcem ent for which the information on this application w ill be used are: (1)
ad m inistration of the registration progra m for the car w ashing and polishing ind ustry, and (2) enforcem ent of California’s labor law s.
7. The follow ing are know n or foreseeable d isclosures of the information contained herein w hich m ay be m ad e pursuant to subd ivision (e) or (f) of Section
1798.24 of the California Civil Code by the Division of Labor Stand ard s Enforcement: Response to a request und er the California Public Record s Act.
8. You have the right to access record s containing your personal inform ation that are maintained by the Division of Labor Stand ard s Enforcem ent. To m ake
an appointm ent to access such record s, please contact the Manager, Licensing and Registration Unit at the ad d ress show n in it em 2 above.
____________________________________________________________________________________________________________________________________________

D O N OT WRITE BELOW THIS LIN E

Registration Annual D ate Received D ate Posted
Fee Assessment
Application N umber______________________

Approved: State Labor Commissioner__________________________________ $ $

 WCI _______________  Articles of Incorporation
Date  LLC Articles of Organization

 IRS ________________  Business License/Regional Regulatory Requirements
Date Cleared  Leased Employee Agreement

 Bond  FBN
 I.D .
 SOS _______________  Citation(s)/Judgment(s) _______________

D ate Date

DLSE 666 (09/05) (English) 4