Fillable Part I To Be Completed by ALL Applicants (Department of Labor)

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Part I To Be Completed by ALL Applicants (Department of Labor)

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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.)
e
Application for a Farm Labor Contractor or
U.S. Department of Labor
Farm Labor Contractor Employee
Wage and Hour Division
Certificate of Registration
Migrant and Seasonal Agricultural Worker Protection Act
1. Application for certificate of registration for:
(Check only one)
FLC Initial Renewal Amended
FLCE Initial Renewal Amended
If renewal, Prior Certificate Number:
Is form FD-258 fingerprint card attached? Yes____ No____
(See Instructions)
2. Name of applicant or applicant’s representative (Please Type or Print)
(Last) (First) (Middle)
Permanent place of residence (Address May Not Be a P.O. Box):
Street: City:
State: Zip Code: Country:
If mailing address is different, please complete the following
(Address May Be a P.O. Box):
Street: City:
State: Zip Code: Country:
Primary Telephone Number:
Alternate telephone:
Social Security Number:
3. Sex: Male Female
Height: ft. in
Weight:
lbs.
Eye color:
Hair color:
4. Date of birth (mo., day, year):
United S
tates citizen: Yes No
If naturalized citizen, provide date:
If visa holder, provide visa no. or temporary worker visa no.:
Visa expiration date
(If applicable):
5. Driving authorization: (To be completed by an “individual”
applicant)
Will you drive a vehicle to transport workers?
Yes No
If “yes”, read instructions and complete the following:
Driver’s license no.:
(Attach copy of license to application)
State:
Date issued:
Expiration date:
Class:
Endorsements:
Restrictions:
A valid doctor's certificate must be submitted every three years.
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:
6. Have you been convicted within the past 5 years, under
State or Federal law, of any of the following crimes?
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.
Yes No
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.
Yes No
(If “Yes,” to a CONVICTION of any of the above, attach a copy
of the final judgment 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.)
Form WH-530
OMB No. 1235-0016
Expires 08/31/2023
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 2
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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 Corporation Partnership Other (Specify)
Applicant name to appear on certificate
(for example, legal name of corporation or doing business as / dba) (Area code) (Number)
If the applicant has submitted any other applications under a different name(s), provide the names here
Business address to be listed on certificate (if different from the permanent place of residence in Item 2)
(Street) (City) (State) (Zip Code)
Date of incorporation: IRS employer identification No.:
State of incorporation: State unemployment insurance reporting no.:
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:
Indicate whether you employ or intend to employ H-2A visa workers. Yes How many? No
Indicate whether you employ or intend to employ H-2B visa workers. Yes How many? No
Location(s) of work (including farm name(s), city, and state): ______________________________ Crops:___________________
Work activities:
10. Will you be directly transporting workers or engaging others to provide transportation?
____ No. Explain how workers will get to the worksite:
Yes.
Number of Workers: Type of vehicle(s) and seating capacity:
If
“No,” proceed to Item 11. If “Yes,” answer the questions below:
Will
any single trip be more than 75 Miles round-trip?
Yes. Is a properly completed WH-514 Vehicle Mechanical Inspection Report attached for each vehicle? Yes No
No. Is a properly completed WH-514a Vehicle Mechanical Inspection Report attached for each vehicle? Yes No
(item 10 continues on next page)
Page 3
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10. continued
How will the applicant comply with the insurance or liability bond requirements? (Check all that apply
and attach proof of
compliance for each of the vehicle insurance or liability bond options listed below.)
☐
Vehicle liability insurance coverage in the amount of not less than $100,000 for each seat in the vehicle.
☐
Liability bond.
☐
State workers’ compensation insurance coverage and a minimum of $50,000 per accident in motor carrier or other
appropriate insurance covering loss or damage to the property of others (excluding cargo).
The workers’ compensation
policy must cover all circ
umstances in which the migrant or seasonal agricultural workers will be transported or, if
necessary,
additional coverage through a liability insurance policy or liability bond must be procured for
transportation not covered by the State law
. (If using workers’ compensation coverage in lieu of vehicle insurance,
the applicant must complete the following additional questions.)
If using state workers’ compensation insurance coverage
in lieu of vehicle insurance, check all circumstances in which the
applicant will transport workers
and sign below:
☐ Daily transportation between living quarters and worksite
☐ Recurring transportation to run errands (e.g., to the grocery store, laundromat, etc.)
☐ Long distance travel between worksites, or to/from the worker’s permanent residence in a different city, state, or country
☐ Other (describe):
________________________________________________________________________________________________
________________________________________________________________________________________________
____________________________________________
I affirm that I have truthfully listed all circumstances in which I will transport workers, and that my workers’
compensation policy covers these circumstances under applicable State law. I further affirm that I will not transport
workers in any circumstances not covered under applicable State law by my workers’ compensation policy.
SIGNATURE OF APPLICANT:
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?
Yes. No.
CERTIFICATION
I certify that compensation is to be received for the intended farm labor contractor services and that all
representations made by me in this application are true to the best of my knowledge and belief.
Applicant’s Signature and Title (if other than individual) and Date
Submit statement identifying all housing to be
used and proof that such housing meets all
applicable Federal and State safety and health
standards.
Give the name and address of all persons
who own or control housing to be used by
migrant agricultural workers in the crew.
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Statement of Intention to Comply with Housing Requirements of the
Migrant and Seasonal Agricultural Worker Protection Act (MSPA)
Section 102(3) of the MSPA requires that an applicant for a certificate of registration with authorization to house migrant
agricultural workers shall file a statement identifying each facility or real property to be used by the applicant to house
any migrant agricultural worker during the period for which registration is sought. 29 U.S.C. § 1812(3); 29 C.F.R.
§ 500.45(c). If the facility or real property is or will be owned or controlled by the applicant, such statement shall provide
documentation showing that the applicant is in compliance with all substantive Federal and State safety and health
standards with respect to each such facility or real property. I hereby declare that I will not house migrant agricultural
workers in any facility or real property I own or control until I have submitted all necessary written evidence and
have been issued a Certificate of Registration with housing authorized. I understand that I may then house migrant
agricultural workers only in facilities or real property which has been authorized by the Secretary of Labor
Signature of Applicant ______________________________________ Date _________________________
Statement of Intention to Comply with Transportation Requirements of the
Migrant and Seasonal Agricultural Worker Protection Act (MSPA)
When using, or causing to be used, any vehicle for providing transportation to migrant and/or seasonal agricultural
workers, I declare that I will ensure that each vehicle conforms to applicable Federal and State safety regulations, that it
has an insurance policy or liability bond in effect which insures me against liability for damage to persons or property
arising from transporting any migrant or seasonal agricultural workers in that vehicle, and that each driver has a valid
and appropriate license, as provided by State law, to operate the vehicle. I further declare that I will not transport
migrant or seasonal agricultural workers in any vehicle I own or control until I have submitted all necessary written
evidence and have been issued a Certificate of Registration with transportation authorized, and that I will maintain the
vehicle(s) in accordance with applicable Federal and State safety regulations, maintain insurance at the required levels,
and transport only in circumstances that are covered by my insurance.
Signature of Applicant ______________________________________ Date _____________________________
Authorization of the Secretary of Labor to Accept Legal Process
The
following authorization is executed pursuant to section 102(5) of the MSPA. 29 U.S.C. § 1812(5); 29
C.F.R.
§ 500.45(e).
“I
do hereby designate and appoint the Secretary of Labor, United States Department of Labor, as my lawful agent to accept
service
of summons in any action against me at any and all times during which I have departed from the jurisdiction in which
such
action is commenced or otherwise have become unavailable to accept service, and under such terms and conditions as
are
set by the court in which such action has been commenced.”
Signature
of Applicant ______________________________________ Date ______________________________________
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Page 5
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PART III – To Be Completed by Any Applicant for a
Farm Labor Contractor Employee (FLCE) Certificate of Registration
12. Employer Identification (Name, Farm Labor Contractor Registration No.):
13. Approximate Date the Planned Farm
Labor Activity Will Begin:
Name:
Number: C-/ / /-/ / / / / / /-/ /-/ / /-/ /
(Month, Day, Year)
CERTIFICATION
I certify that I am an employee of the farm labor contractor identified above and will perform farm labor contracting
activities only for that farm labor contractor and for no other farm labor contractor. I certify that all representations made
by me in this application are true to the best of my knowledge and belief.
Signature of Applicant Date
Authorization of the Secretary of Labor to Accept Legal Process
The following authorization is executed pursuant to section 102(5) of the MSPA. 29 U.S.C. § 1812(5);
29 C.F.R. § 500.45(e).
“I do hereby designate and appoint the Secretary of Labor, United States Department of Labor,
as my lawful agent to accept service of summons in any action against me at any and all
times during which I have departed from the jurisdiction in which such action is commenced or
otherwise have become unavailable to accept service, and under such terms and conditions as
are set by the court in which such action has been commenced.”
Signature of Applicant Date
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Instructional and Informational Guide for
Applying for a Certificate of Registration
For Further Details, Refer to the Regulations (29 C.F.R. Part 500) and to the U.S. Department of Labor Publication,
“Migrant and Seasonal Agricultural Worker Protection Act (MSPA).”
N
OTE: Submission of this application form does not authorize the applicant to engage in farm labor contracting
activities. If the application is approved, the applicant will be issued either a Farm Labor Contractor (FLC) or a Farm
Labor Contractor Employee (FLCE) Certificate of Registration.
This application is divided into three parts: Part I is to be completed by all applicants and contains general
identifying information. Part II is to be completed only by applicants applying for a FLC Certificate of
Registration. Part III is to be completed only by applicants applying for a FLCE Certificate of Registration.
If you are applying for certificate renewal, your current certificate may be temporarily extended by the filing of a
properly completed and signed application at least thirty (30) days prior to the expiration date of your current
certificate.
I
f you are amending your current certificate to add a vehicle, housing facility, or real property that you will own,
operate, or control, you must submit the appropriate information to obtain transportation or housing authorization
within ten (10) days after you obtain or learn of the intended use of such vehicle, housing facility, or real property.
I
tem 1 – Application for certificate. (Please check only one block.)
If no FLC or FLCE (whichever is applicable) Certificate of Registration (Form WH-511 or WH-513) has ever been
issued to you by the U.S. Department of Labor (even though you previously applied for one), check “initial.” If your
certificate has expired, check “initial.” If a certificate has been issued to you by the U.S. Department of Labor and that
certificate has not yet expired, check “renewal” and enter the number of the last certificate issued to you. If a certificate
has been previously issued to you, but circumstances have changed that necessitate an amendment to your original
certificate (e.g., change of permanent address, or to add or remove an authorization to transport, house, or drive
covered workers), check “amended.” If you are applying for an initial certificate, attach a completed Form FD-258,
Fingerprint C
ard, to this application. If applying for a renewal certificate and your last Fingerprint Card is more than
three years old, submit another completed Form FD-258. A Fingerprint Card is not required for applications to “amend”
a Certificate of Registration.
Type of Certificate – Check one block to indicate whether applying as a FLC or as a FLCE.
Items 2-4 – Name of applicant or applicant representative. This item is to identify the person submitting the
application. If the applicant is applying for a certificate as an individual, items 2-4 refer to the applicant’s own
information. If the applicant is a corporation, partnership or other, items 2-4 refer to the applicant representative’s
information. The applicant representative is a person who is authorized to act on behalf of the organizational
applicant, such as an owner, president, or chief executive officer.
I
tem 5 – If you drive a motor vehicle to transport migrant or seasonal agricultural workers and you are applying for an
initial certificate, submit a completed Form WH-515, Doctor’s Certificate, with this application. If applying for a renewal
certificate and your last Doctor’s Certificate is more than three years old, submit another completed Form WH-515.
We also allow the submission of unexpired, properly completed Department of Transportation doctor certification
forms such as the DOT Medical Examiner's Certificate or the DOT Form 649-F Medical Examination Report for
Commercial Driver Fitness Determination.
I
tem 7 – Operating as an individual or organization. If application is for a corporation, partnership, or other organization,
each officer, director, partner, or employee who will engage in any of the covered farm labor contracting activities on
behalf of the organization must obtain either a FLC Certificate of Registration or a FLCE Certificate of Registration
prior to engaging in farm labor contracting activities.
Applicant name to appear on certificate. If the applicant is an i
ndividual, list the applicant’s name and any trade
names or doing business as (dba) names. If the applicant is a corporation, partnership or other, list the applicant’s
legal name and any applicable trade or dba names
Page 7
– Continued on Next Page –
.
B
usiness address to be listed on the certificate. List the business address here if different from the applicant or
applicant representative’s permanent place of residence address listed in item 2. If the business address is the
mailing address listed in item 2, you may write “mailing address.” If this field is left blank, the certificate will list the
applicant or applicant representative’s permanent place of residence collected in item 2.
Item 8 – For a definition of “employ,” see 29 C.F.R. § 500.20(h). All other terms have their common meaning.
Item 10 – A certificate of registration Authorizing the Applicant to Transport Migrant Workers in connection with
the applicant’s business, activities, or operations as a farm labor contractor shall be issued only after the following
have been submitted:
1. Evidence of compliance with applicable Federal and State rules and regulations as follows:
All vehicles which the applicant is to provide or arrange to furnish to transport migrant or seasonal
agricultural
workers must first be inspected and approved each year by a Federal or State inspector or by
a responsible
garage or mechanic. A completed Form WH-514 or WH-514a, Vehicle Identification and
Mechanical Inspection
Report, must be submitted to the U.S. Department of Labor each year for each
vehicle to be used to transport
workers.
2. Evidence of compliance with the insurance or financial responsibility requirements of the Migrant and
Seasonal A
gricultural Worker Protection Act and the Regulations issued thereunder.
T
hese requirements are found at 29 C.F.R. §500.120-.128, and are summarized in WHD’s Fact Sheet 50
found at https://www.dol.gov/agencies/whd/fact-sheets/50-mspa-transportation. The applicant must check the
type(s) of insurance or liability bond and attach the relevant evidence.
If workers’ compensation coverage is provided in lieu of vehicle insurance, complete the additional fields in item 10
and submit proof of a worker’s
compensation coverage policy of insurance plus a $50,000 property damage
policy, or a Farm Labor
Contractor Motor Vehicle Liability Certificate of Insurance showing that workers are
covered by
liability insurance while being transported. 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.
Item 11 – A farm contractor is considered an “owner” of migrant agricultural worker facilities or real property if the
farm
labor contractor has a legal or equitable interest in such facilities or real property. A farm labor contractor is
in “control”
of facilities or real property when the contractor is in charge of or has the power or authority to
oversee, manage,
superintend, or administer facilities or real property either personally or through an authorized
agent or employee
acting in any of the aforesaid capacities.
Proof that facilities or real property owned or controlled by a farm labor contractor complies with applicable Federal
and State safety and health standards can be satisfied by one of the following:
1. A certification issued by a State or local health authority or other appropriate agency, or
2. A dat
ed and signed written request for the inspection of a facility or real property made to the appropriate
State
or local agency at least forty-five (45) days prior to the date on which it is to be occupied by migrant
agricultural
workers.
Item 12 – Section 101(b) of the MSPA requires that a person issued a Farm Labor Contractor Employee
Certificate
of Registration be an employee of a person holding a valid Farm Labor Contractor Certificate of
Registration. 29 U.S.C. § 1811(b). The employer identification should be in the name in which your
employer’s Farm Labor
Contractor Certificate was issued. If no certificate has been issued but your employer has
applied, enter “applied” and
the date in the space provided for the registration number.
Submission of Application
Send first class mail, certified mail, and USPS Express Mail to:
U.S. Department of Labor, Wage and Hour Division, Farm Labor Certificate Processing
90 Seventh Street, Suite 11-100
San Francisco, CA 94103
Page 8
Applies ONLY to Part II Applicants:
Statement of Intention to Comply with Housing Requirements. Any applicant for a Farm Labor Contractor
Certificate or Registration who answers “yes” in item 11 must attest that they will not house migrant agricultural workers
in any facility or real properly under their ownership or control until all necessary written evidence has been submitted
and a certificate of registration Authorizing the Applicant to House Migrant Workers has been issued.
Statement of Intention to Comply with Transportation Requirements. All applicants for a Farm Labor Contractor
Certificate of Registration must attest that any vehicle they use, or cause to be used, to transport migrant and/or
seasonal agricultural workers complies with applicable Federal and State safety regulations, has appropriate and
adequate insurance, and is driven by a driver with a valid and appropriate license, as provided by State law, to operate
the vehicle.
Applies to BOTH Part II and Part III Applicants:
Certification. This application must be signed by you before a Certificate of Registration will be issued. The complet-
ed application and related forms and documents should be submitted to any local employment service office or other
designated office in the State.
Authorization to Accept Legal Process. Each applicant for a Certificate of Registration, in addition to all other
requirements, must sign the statement authorizing the Secretary of Labor to accept legal service of summons in
any action against the applicant when such applicant is unavailable to accept summons, or has departed from the
jurisdiction of the court in which such action is commenced.
Important–Privacy Act and Paperwork Reduction Act Public Burden Statement
1. The purpose of this form is to provide the Department of Labor with sufficient information to identify and determine
the qualifications of the applicant for the requested certificate to serve as a FLC or FLCE.
2. In addition to the Department of Labor using this collection of information in the FLC/FLCE registration process,
information from this form may be used in the course of presenting evidence to a court of administrative tribunal or in
the course of settlement negotiations.
3. F
ailure to provide the information precludes the issuance of necessary documents required under the law. Your
social security number is used for identification purposes; its submission is authorized by 29 C.F.R. Part 500.
4. Information collected in response to this request may be disclosed in accordance with the provisions of the Freedom
of Information Act, 5 U.S.C. § 552; the Privacy Act, 5 U.S.C. § 552(a); and related regulations, 29 C.F.R. Parts 70, 71.
The Department of Labor makes no express assurances of confidentiality regarding this collection of information.
5. Submission of this information is required under the MSPA in order to obtain the benefit of a FLC or FLCE Certificate
of Registration. 29 U.S.C. §§ 1811-1812; 29 C.F.R. § 500.44-.47. Unlawfully engaging in FLC activities without a
valid FLC/FLCE Certificate of Registration may subject you to civil or criminal penalties. See 29 U.S.C. §§ 1851-1853;
29 C.F.R. 500 Subpart E.
6. Persons are not required to respond to this collection of information unless it displays a currently valid OMB Control
Number.
7. The Department of Labor estimates that it will take an average of 30 minutes to complete this collection of
information, including the time for reviewing instructions, searching existing data sources, gathering and maintaining
the data needed and completing and reviewing the collection of information. If you have any suggestions for reducing
this burden, send them to the Administrator, Wage and Hour Division, Room S-3502, 200 Constitution Avenue, N.W.,
Washington, DC 20210.
DO NOT SEND THE COMPLETED FORM TO THIS OFFICE, SEND TO THE ADDRESS APPEARING ON
PAGE 7 OF THIS FORM.
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Part I To Be Completed by ALL Applicants (Department of Labor)

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Completed 26 January 2021

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