Financial Oversight and Special Entities Division

Change in the name of the Registrant conducting business in North Carolina.

• Effective Date:
• New Name:
• Attach legal filings or amendments supporting the name change
• Attach sample copies of the revised client proposal and client agreement

Note: If a Registrant has changed its name once during a calendar year, the Registrant shall not change its name again unless the name change is approved by the Commissioner.

Change in the location of the Registrant’s primary business office.

• Effective Date:
• New Address:
• New Mailing Address:

Change in the location of the business records maintained by the Registrant.

• Effective Date:
• New Location Address:

Addition of a business office providing professional employer services in North Carolina.

• Effective Date:
• New Office Address:

Deletion of a business office providing professional employer services in North Carolina.

• Effective Date:
• Office Address to be Deleted:

Change in the location of a business office providing professional employer services in North Carolina.

• Effective Date:
• Old Address:
• New Address:

Addition of Controlling Person.

• Effective Date:
• Name of new Controlling Person:
• Attach a Biographical Affidavit

Deletion of Controlling Person

• Effective Date:
• Name of Deleted Controlling Person:

Other (to include change in business structure, bankruptcy filing, any regulatory or judicial action taken against the Registrant, etc.)

• Effective Date:
• Description of change: