Form WH-530 Application for a Farm Labor Contractor or Farm Labor Co

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: 08-31-2015

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.)
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
FLCE

Initial
Initial

 Renewal  Amended
 Renewal  Amended

Street:
City:

If renewal, Prior Certificate Number:
2. Name to Appear on Certificate: (Please Type or Print)

State:

ZIP Code:

5. Driving Authorization:
Will You Drive a Vehicle to Transport Workers?
(To be completed by an “Individual” applicant)

Name (Last)

(First)

(Middle)


No

 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:

City:

State:

ZIP Code:

Expiration Date:

Date Issued:
Class:

Restrictions:
A valid Doctor's Certificate must be submitted every three years.

Telephone Number:
(

Last Six (6) Digits of
Social Security Number:

)

3. Height

ft.

in.
lb.

Weight
Sex:

Color of Eyes:



Male



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?

Color of Hair:

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.

Female

Date of Birth (Mo., Day, Year):
(a) United States Citizen:



Yes



If naturalized citizen, give date:
(b) Alien Registration No.:
(Attach copy of card to application)

 Yes
No (if No, Go to (b))



No

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.

 Yes

Expiration Date (If any):
(c) Visa No. or Temporary Worker Visa No.:



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.)

Expiration Date (If any):

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.
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



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Form WH-530
Rev. Dec. 2011

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)

If a Corporation, Give Legal Name (and doing business as / dba), Address, Telephone Number, Date and State of Incorporation.

(Please Type or Print)

(
Name of Applicant (or Legal Name of Corporation, and doing business as / dba)

)
(Area Code)

(Number)

Name of Representive for Purposes of this Application
(Street)

(City)

Date of Incorporation:
State of Incorporation:

(If None, Enter “None”)
(If None, Enter “None”)

(State)

(ZIP Code)

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

 Employ

Solicit

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

(If yes, how many

).

No

(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?


Yes (Submit statement identifying all housing to be used
and proof that such housing meets all applicable
Federal and State safety and health standards.)

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
No (Give the name and address of all persons who

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own or control housing to be used by migrant
agricultural workers in the crew.)

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

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

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

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Date

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

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Date

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).”
NOTE: 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.
Item 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 Card, 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.
Item 2 – Person making application. This item is to identify the person submitting the application regardless of whether
they are applying for a certificate in their own name or on behalf of an organization.
Item 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.
Item 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 so engaging in farm labor contracting activities.
Item 8 – For a definition of “employ,” see 29 C.F.R. § 500.20(h)(4). All other terms have their common meaning.

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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:
a. 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.
b. Evidence of compliance with the insurance or financial responsibility requirements of the Migrant and
Seasonal Agricultural Worker Protection Act and the Regulations issued thereunder. 29 C.F.R.
§ 500.120-.128.
If worker’s compensation coverage is provided in lieu of vehicle insurance, 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.
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 dated 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
If the applicant’s permanent place of residence is in Alaska, Arkansas, Arizona, American Samoa, California,
Colorado, Guam, Hawaii, Idaho, Louisiana, Montana, Nevada, New Mexico, North Dakota, Oklahoma, Oregon, South
Dakota, Texas, Utah, Washington, or Wyoming, the application should be sent to:
U.S. Department of Labor
Wage and Hour Division
Western Farm Labor Certificate Processing
90 Seventh Street, Suite 13-100
San Francisco, CA 94103
If the applicant’s permanent place of residence is anywhere else in the country, then the application should be sent to
one of the following two addresses.
Send first class mail, certified mail, and USPS Express Mail to:
U.S. Department of Labor
Wage and Hour Division
Southeast Farm Labor Certificate Processing
P.O. Box 56447
Atlanta, GA 30343-0447

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Send all other ground and express courier services to:
U.S. Department of Labor
Wage and Hour Division
Southeast Farm Labor Certificate Processing
233 Peachtree Street NE, Suite 610
Atlanta, GA 30303

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.

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 completed 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. Failure 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 6 OF THIS FORM.

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