Application for a Farm Labor Contractor or Farm Labor Contractor Employee Certificate of Registration Migrant and Seasonal Agricultural Worker Protection Act U.S. Department of Labor Wage and Hour Division OMB No. 1235-0016 Expires: 10-31-2015 Part I ­ To Be Completed by ALL Applicants Please read instructions before completing this application. No Farm Labor Contractor (FLC) or Farm Labor Contractor Employee (FLCE) Certificate of Registration may be issued unless a completed form has been received (29 U.S.C. 1801 et. seq.) 1. Application for Certificate of Registration for: (Check only one block.) FLC FLCE 4. Give Address to Which Notices and Documents Should Be Sent (Address may include a P.O. Box): Street: City: State: ZIP Code: Initial Initial Renewal Amended Renewal Amended If renewal, Prior Certificate Number: 2. Name to Appear on Certificate: (Please Type or Print) 5. Driving Authorization: Will You Drive a Vehicle to Transport Workers? (To be completed by an "Individual" applicant) Name (Last) (First) (Middle) No State: Yes If "Yes," Read Instructions and Complete the Following: (Attach copy of license to application) Driver's License No.: Permanent Place of Residence (Address May Not Be a P.O. Box): Street: City: State: ZIP Code: Expiration Date: Endorsements: Restrictions: Date Issued: Class: A valid Doctor's Certificate must be submitted every three years. Telephone Number: ( ) Last Six (6) Digits of Social Security Number: Doctor's Certificate Expiration Date: Is Doctor's Certificate attached? Yes No Will Drive Workers for Self Other If "Other," specify the name and FLC Registration Number: 3. Height Weight Sex: ft. in. lb. Color of Eyes: Color of Hair: Female 6. Have you been convicted within the past 5 years, under State or Federal law, of any of the following crimes? A. Any crime relating to gambling, or to the sale, distribution, or possession of alcoholic beverages, in connection with or incident to any farm labor contracting activities. Male Date of Birth (Mo., Day, Year): (a) United States Citizen: Yes Yes No (if No, Go to (b)) No If naturalized citizen, give date: (b) Alien Registration No.: (Attach copy of card to application) B. Any felony involving robbery, bribery, extortion, embezzlement, grand larceny, burglary, arson, violation of narcotics laws, murder, rape, assault with intent to kill, assault which inflicts grievous bodily injury, prostitution, peonage, or smuggling or harboring individuals who have entered the United States illegally. Expiration Date (If any): (c) Visa No. or Temporary Worker Visa No.: Expiration Date (If any): Yes No (If "Yes," to a CONVICTION of any of the above, attach a copy of the final judgement in the case to your application. If you do not possess a copy of the final judgement, attach an additional sheet listing the crime, date, place of conviction, and the court of jurisdiction.) A false answer or misrepresentation to any question may be punishable by fine or imprisonment. 18 U.S.C. § 1001, 29 U.S.C. §§ 1851-1853; 29 C.F.R. § 500.6. Page 1 ­ Continued on Next Page ­ Form WH-530 Rev. Dec. 2011 American LegalNet, Inc. www.FormsWorkFlow.com NOTE: IF YOU ARE APPLYING AS A FARM LABOR CONTRACTOR, CONTINUE WITH PART II IF YOU ARE APPLYING AS A FARM LABOR CONTRACTOR EMPLOYEE, SKIP PART II AND GO DIRECTLY TO PART III (A Farm Labor Contractor Employee is a person who performs farm labor contracting activities solely on behalf of a [specific] Farm Labor Contractor holding a valid Certificate of Registration and is not an independent Farm Labor Contractor who would be required to register under the Act in his/her own right.) Part II ­ To Be Completed by Farm Labor Contractor (FLC) Applicant 7. The Applicant is a/an: (Check One) Individual (Please Type or Print) Corporation Partnership Other (Specify) ( ) (Area Code) (Number) If a Corporation, Give Legal Name (and doing business as / dba), Address, Telephone Number, Date and State of Incorporation. Name of Applicant (or Legal Name of Corporation, and doing business as / dba) Name of Representive for Purposes of this Application (Street) (City) (If None, Enter "None") (If None, Enter "None") (State) (ZIP Code) Date of Incorporation: State of Incorporation: IRS Employer Identification No. State Unemployment Insurance Reporting No. (If None, Enter "None") 8. Check Each Activity to Be Performed Involving Migrant and/or Seasonal Agricultural Workers for Agriculture Employment: Recruit Hire Furnish Transport Solicit Employ 9. Give the Greatest Number of Migrant and/or Seasonal Agricultural Workers That Will Be in the Crew(s) at Any Time: The intended farm labor contracting activities will begin approximately: Indicate whether you employ or intend to employ H-2A visa workers. Indicate whether you employ or intend to employ H-2B visa workers. (Month, Day, Year) Yes Yes No No (If yes, how many (If yes, how many ). ). Describe your method of operation (Specify crops, agricultural activity, places of employment, location, etc.): 10. Will You Be Directly Transporting Workers or Engaging Others to Provide Transportation? Yes (Give number, type and seating capacity of vehicles used to transport migrant and seasonal agricultural workers. Submit proof of compliance with the insurance or financial responsibility requirements. Note that workers' compensation provides specific coverage and may not cover out-of-state travel or non-work-related travel. Also note that if transportation authorization is issued based on a workers' compensation insurance policy provided by a specific employer, the insurance coverage is limited to such times as the applicant is actually working for that employer.) Will Any Single Trip Be More Than 75 Miles Round-trip? Yes (Submit a properly completed WH-514 Vehicle Mechanical Inspection Report.) No (Submit a properly completed WH-514a Vehicle Mechanical Inspection Report.) No (Explain how workers get to the work site.) 11. Will You Own or Control Any Facility or Real Property Which Will Be Used by Migrant Agricultural Workers in the Crew(s) at Any Time? (Submit statement identifying all housing to be used Yes and proof that such housing meets all applicable Federal and State safety and health standards.) (Give the name and address of all persons who No own or control housing to be used by migrant agricultural workers in the crew.) Page 2 ­ Continued on Next Page ­ American LegalNet, Inc. www.FormsWorkFlow.com CERTIFICATION I certify that compensation is to be received for t