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. 125-00 Expires: 0-3-201 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.) 4. Give Address to Which Notices and Documents Should Be Sent (Address may include a P.O. Box): 1. Application for Certificate of Registration for: (Check only one block.) FLC Initial Renewal Amended FLCE Initial Renewal Amended Street: City: ,I UHQHZDO 3ULRU &HUWLILFDWH 1XPEHU 2. 1DPH WR $SSHDU RQ &HUWLILFDWH: (Please Type or Print) State: ZIP Code: 5. DrivLQJ $XWKRUL]DWLRQ Will You Drive a Vehicle to Transport Workers? (To be completed by an “Individual” applicant) No Name (Last) (First) (Middle) Yes If “Yes,” Read Instructions and Complete the Following: Driver’s License No.: (Attach copy of license to application) Permanent Place of Residence (Address May Not Be a P.O. Box): State: Street: Endorsements: Expiration Date: Date Issued: Class: Restrictions: City: State: ZIP Code: $ YDOLG 'RFWRU V &HUWLILFDWH PXVW EH VXEPLWWHG HYHU\ WKUHH \HDUV Telephone Number: ( Last Six (6) Digits of Social Security Number: ) 3. Height ft. in. OE. :eight Sex: Male Color of Eyes: 'RFWRU V &HUWLILFDWH ([SLUDWLRQ 'DWH: ,V 'RFWRU V &HUWLILFDWH DWWDFKHG"