Disclosure Addendum {5380}

Worker Leasing Application Disclosure Addendum Forms 2466 and 5364 Provide a separate Disclosure Addendum for each 223yes224 response to questions under the 223Applicant business history224 or 223Controlling person disclosures224 section of the worker leasing license application. (OAR 436 - 180 - 0140) Person or entity Name Applicant Controlling person Addendum to which question? Applicant business history: a b c d Controlling person disclosures: a b c d Provide all applicable detail below. Add 223n/a224 if not applicable. Do not leave sections blank. You may also provide additional information you believe would assist the division in evaluating for licensure. Case name and number: Name and location of court or jurisdiction: License, registration, or certification number: Nature and date of action: Current status or final outcome (attach relevant documentation): Other information (attach additional pages or documents as necessary): 5380 440 - 5380 (7/18/DCBS/WCD/WEB) American LegalNet, Inc. www.FormsWorkFlow.com