Professional Documents
Culture Documents
BUSINESS NAME
DBA (If DBA name is different from legal name listed above, attached a Certificate of Assumed Name filed and stamped by the Minnesota Secretary of State)
BUSINESS ADDRESS (PO Box must include RR# or street address) CITY STATE ZIP CODE
OWNER INFORMATION
List name(s), address(es), date(s) of birth and social security number(s) of all owner(s). Attach additional pages if needed.
OWNER FULL NAME DATE OF BIRTH SOCIAL SECURITY NUMBER
This material can be made available in different forms, such as large print, Braille or on a tape. To request, call 1-800-342-5354
(DIAL-DLI) Voice or TDD (651) 297-4198.
Office Use Only PROCESSING DATE CERTIFICATE OF EXEMPTION NUMBER
I certify that this document has not been changed in any manner from the form adopted by the Department of Labor and Industry.
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Minnesota Department of Labor and Industry
CCLD Licensing and Certification/Residential Certificate of Exemption
443 Lafayette Road N.
St. Paul, MN 55155 Checklist
(651) 284-5065
Failure to include all requested information will result in your application being returned to you.
Complete the Bureau of Criminal Apprehension Criminal Background Check form and submit with the complete
application.
Enclose the Assumed Name Certificate, if applicable, and be sure the name on the application is identical to the
Assumed Name Certificate.
Attach a written, detailed explanation for any questions answered “yes” on the application.
Sign and date the application. Mail all documents to address above. License will be mailed to business address after
application processing. Note: Application processing is not currently available at the DLI public service counter.
Note: Secretary of State business filing and Assumed Name Certificate application information is available via telephone
(651) 296-2803, or online at www.sos.state.mn.us.
CORPORATIONS
A copy of your Articles of Incorporation or Certificate of Incorporation. Both of these documents must have the Secretary
of State’s file number on them.
A list of the names and addresses of all corporate officers, directors and shareholders owning more than 10 percent of the
outstanding stock in the corporation.
Assumed Name Certificate if the DBA is different from the corporate name.
PARTNERSHIPS
A partnership agreement that lists the names and addresses of each partner, amount of ownership and signed by each
partner.
Any individual, corporation, partnership or limited partnership that is doing business in the state of Minnesota under a
name other than the full name (first and last) of each person involved in the business, or the legal corporate or partnership
name, must file an assumed name.
Examples: "John Smith Construction" would not be required to file if John Smith is the owner of the business. However,
"Smith's Construction" would be required to file because it does not contain the full first and last name of the owner.
Similarly, the legally incorporated company "ABC Construction" does not need to file an assumed name, because that is its
legal corporate name. If an entity does business under any name other than the legal corporate name, an assumed name
filing would be required. The reason for filing an assumed name is not to protect the name against use by other persons,
but to provide information to the consumer about the identity of the business owner.
Applications for assumed name filings may be obtained from the Secretary of State, online at www.sos.state.mn.us, by
mail at 180 State Office Building, St. Paul, MN 55155, or by telephone at (651) 296-2803. Instructions for filing an
assumed name are provided on the application form.
This material can be made available in different forms, such as large print, Braille or on a tape. To request, call 1-800-342-5354
(DIAL-DLI) Voice or TDD (651) 297-4198.
RBC 20 (12/06)