Form WH-535 APPLICATION FOR A FARM LABOR CONTRACTOR EMPLOYEE CERTIFI

WH-535 Application for a Farm Labor Contractor Employee Certificate of Registration (Application for “blue card”)

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Please read instructions before completing this application. No Farm Labor Contractor Certificate of Registration may be issued unless a completed form has been received. Please do not staple this form or accompanying documents.

Complete this form if you are a farm labor contractor employee, meaning that you are:

• an employee of a registered farm labor contractor; and

• seeking to perform farm labor contracting activities solely on behalf of your employer.

Do not complete this form if you are a farm labor contractor, meaning that you recruit solicit, hire, employ furnish, or transport migrant or seasonal agricultural workers for money or other benefit. If you are a farm labor contractor, please register using form WH-530.

Do not complete this form if you are seeking to amend a current farm labor contractor or farm labor contractor Certificate of Registration. To request an amendment, please use form WH-540.

1. Type of Application for certificate of registration: (Check only one)

☐ Initial ☐ Renewal

Previous/current certificate number (if applicable): __________________________________________

Farm Labor Contractor employer name: _____________________________________________________________

Farm Labor Contractor employer registration number: C-___ ___ - ___ ___ ___ ___ ___ ___ -___ - ___ ___ - ___ __

2. Firefighters

Will the applicant engage in firefighting activities? ☐Yes ☐No

If yes, specify the firefighting activities:

Proceed to Section 3.

3. Information to appear on certificate

First Name:________________________________________ Middle Name (optional):________________

Last Name: __________________________________________

Has the applicant ever been known by any other names (e.g., maiden name)? _______________________

Social Security Number: _________________________ Date of Birth (mm/dd/yyyy): ________________

Phone number: _____________________________ Email address (optional): _______________________________

Proceed to Section 4.

4. Address

Applicant’s permanent place of residence (this may not be a P.O. Box):

Address:

City: ________________ State: ________________ Zip Code: ________ Country: _____________

Mailing address, if different from address above:

Address:

City: State: Zip Code: ______________ Country: _________________

Proceed to Section 5.

5. farm labor contracting activities to be performed

Check each activity to be performed involving migrant and/or seasonal agricultural workers for agricultural employment under this certificate:

☐ Recruit ☐ Hire ☐ Furnish ☐ Transport ☐ Solicit ☐ Employ

Location of work with as much specificity as possible, including State, city, and farm name(s), if known:

__________________________________________________________________________________________________

Proceed to Section 6.

6. Criminal history

Has the applicant 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 the applicant marked "Yes" to A or B, attach a copy of the final judgment. ☐ Attached

A properly completed Form FD-258 Fingerprint Card must be submitted to WHD at least once every three years. Is Form FD-258 attached to this application?

☐ My completed Form FD-258 is attached. Proceed to Section 7.

☐ I previously submitted a completed Form FD-258 within the last three years. Proceed to Section 8.

7. Form FD-258 Fingerprint Card

Read and sign the statement below.

The completed form FD-258 submitted with your application will be used to check the criminal history records of the FBI. Applicants will have the opportunity to complete or challenge the accuracy of the information in this FBI identification record. Procedures for obtaining a change, correction, or updating of an FBI identification record are set forth in 28 CFR 16.34. Your signature below acknowledges this agency has informed you of your privacy and redress rights.

SIGNATURE: ______________________________________________ DATE: __________________________

Proceed to Section 8.

8. Does the applicant require driving authorization?

Will the applicant drive a vehicle to transport workers?

☐ Yes. If Yes, proceed to Section 9 to apply for driving authorization.

☐ No. If No, proceed to Section 10.

9. Application for Driving Authorization

In what State(s) will the applicant be driving workers? _____________________________________________________________________________________

Attach a copy of the applicant’s driver’s license (front & back). ☐ Attached

Attach a copy of the applicant’s doctor’s certificate (WH-515 or applicable Department of Transportation Form).

☐ Attached ☐ Not applicable (the applicant has a currently valid doctor’s certificate on file with WHD)

Proceed to Section 10.

10. Certifications and authorizations

All applicants must read and sign all certifications and authorizations in this Section.

Certification of Truthfulness in Application

I certify that compensation is to be received for the intended farm labor contractor activities and that all representations made by me in this application are true to the best of my knowledge and belief.

SIGNATURE: ______________________________________________ DATE: __________________________

Authorization of the Secretary 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: ___________________________________________ DATE: _____________________

instructions for WH-535 initial or renewal Application for a Farm Labor Contractor Employee Certificate of Registration (Application for “blue card”)

PURPOSE OF FORM wh-535

The Migrant and Seasonal Agricultural Worker Protection Act (MSPA) protects migrant and seasonal agricultural workers by establishing employment standards related to wages, housing, transportation, disclosures and recordkeeping. Generally, the MSPA applies to any person (or business) who recruits, solicits, hires, employs, furnishes, or transports migrant or seasonal agricultural workers (the MSPA refers to these activities as "farm labor contracting activities"). In order to legally operate as a farm labor contractor (FLC) or farm labor contractor employee (FLCE), individuals and companies must apply to the U.S. Department of Labor for a Certificate of Registration authorizing the applicant to engage in farm labor contracting activities. During the period for which the Certificate of Registration is in effect, each FLC and FLCE must notify the Department of Labor to amend the certificate to reflect important changes, such as a change in address.

Certain persons and organizations, such as small businesses meeting the exemption criteria of 29 U.S.C. § 213(a)(6)(A), are exempt from the MSPA and are not required to register as farm labor contractors. In addition, establishments meeting the MSPA definition of an "agricultural association" or "agricultural employer," are not required to register as farm labor contractors.

The Wage and Hour Division of the U.S. Department of Labor administers and enforces the MSPA. For more information, contact the Wage and Hour Division through its website at https://www.dol.gov/agencies/whd/contact or by telephone at 1-866-4US-WAGE (1-866-487-9243), TTY: 1-877-889-5627. The federal regulations implementing MSPA appear in 29 C.F.R. Part 500. The regulations are available here: https://www.dol.gov/agencies/whd/laws-and-regulations/laws/mspa

wHO MAY SUBMIT A FORM wh-535?

This form is used to apply to the U.S. Department of Labor’s Wage and Hour Division (WHD) for an initial or renewal Certificate of Registration, authorizing the applicant to engage in “farm labor contracting activities” as a Farm Labor Contractor Employee (FLCE). MSPA Section 101(b) requires that a person issued a FLCE certificate be the employee of a registered Farm Labor Contractor (FLC), and may perform farm labor contracting activities solely on behalf of such FLC.

If you are an independent FLC performing farm labor contracting activities for money or other valuable on his/her own behalf, complete form WH-530.

If you are seeking to amend an existing certificate, complete form WH-540.

gENERAL wh-535 iNSTRUCTIONS

IMPORTANT: Submitting the application form does not authorize you to engage in farm labor contracting activities. If the application is approved, you will be issued an FLCE Certificate of Registration, at which time you may begin to engage in the authorized activities. No Farm Labor Contractor Employee Certificate of Registration may be issued unless a completed form has been received (see 29 U.S.C. 1811). The application will be returned without processing if it is incomplete, and the applicant will be required to resubmit.

In addition, depending upon the specific activities for which you are seeking authorization (i.e., driving covered workers), additional forms/documentation must be submitted with your application. Each section of this application requiring additional form(s) or documentation will include the name and location of the form(s) and/or a description of the specific documentation needed.

1. Type of Application for certificate of registration

Check one box to indicate whether the applicant is submitting an initial or renewal application.

Check INITIAL if:

no certificate of registration has ever been issued to the applicant;

a certificate was previously issued to the applicant, and it is now expired; or

a certificate was previously issued to the applicant, and it is due to expire in less than 30 days. (For example, if today is January 1^st, and the current certificate is due to expire on January 15^th.)

Check RENEWAL if:

a certificate of registration was previously issued to the applicant, and it is not yet expired; and

the certificate is due to expire in 30 days or more.

Identify the current or previous certificate number, if applicable, regardless if the application is an initial or renewal.

Identify your employer’s FARM LABOR CONTRACTOR NAME. The name listed in this field should be the same name listed on your employer’s MSPA certificate of registration.

Identify your employer’s FARM LABOR CONTRACTOR REGISTRATION NUMBER. If your employer has applied, but has not yet been issued a certificate, write “applied” in this space. Please note that if your employer does not yet have a valid certificate and has not yet applied for a certificate, WHD is unable to process your application.

Note: A MSPA certificate may be temporarily extended by the timely filing of a properly completed and signed application for renewal at least 30 days before the expiration of your current certificate. If the application for renewal is filed by regular mail or delivered in person, it must be received by the Department at least 30 days prior to the expiration date on the current certificate. If the application for renewal is filed by certified mail, it must be mailed at least 30 days prior to the expiration date on the current certificate.

2. Firefighters

Check YES if the applicant will be engaged in performing any firefighting activities. If checking YES, provide specific examples of firefighting activities the applicant will perform.

3. Information to appear on certificate

Provide the first name, middle name, and last name to appear on the certificate.

Provide the applicant’s Social Security Number and date of birth.

Identify if the applicant ever been known by other names, such as a maiden name or alias.

Enter the PHONE NUMBER and EMAIL ADDRESS (optional) to be used to contact the applicant regarding the application.

4. Address

Provide the applicant’s permanent address. This address must be for a physical location where the individual resides; it may not be a P.O. Box.

If the applicant has a different mailing or business address from its permanent address, list this address.

5. farm labor contracting activities to be performed

Check the box for each activity to be performed for purposes of this certificate. At least one box must be checked. The MSPA regulations at 29 CFR 500.20(h) provide a definition of “employ.” All other terms have their common meaning.

Provide the location of work with as much specificity as possible, including city, state, and farm name(s), if known. If the exact location is unknown, provide as much detail as possible.

6. Criminal history

Identify if the applicant has been convicted of any of the listed crimes in the previous five year period.

Check YES to part A if he/she was convicted of any crime described in this part that was associated with any farm labor contracting activities.

Check YES to part B if he/she was convicted of any crime described in this part REGARDLESS of whether the crime was committed in connection with any farm labor contracting activities.

If checking yes to part A and/or B, attach a copy of the final judgment to this application. A final judgment is a court document that contains the final disposition of the case (e.g., convicted, acquitted, dropped, etc.).

Form FD-258 Fingerprint Card must be fully completed by the applicant if applying for an INITIAL certificate, or if applying for a certificate RENEWAL and the last FD-258 was submitted to WHD more than three years ago. Identify whether the Form FD-258 is attached or has previously been provided within the preceding three-year period.

7. Form FD-258 Fingerprint Card

If attaching Form FD-258, read and sign the statement regarding privacy and redress rights.

8. Does the applicant require driving authorization?

If seeking driving authorization, complete Section 9, Application for Driving Authorization.

9. Application for Driving Authorization

If applying for driving authorization, attach:

• A clear photocopy of the applicant’s current and valid driver’s license, both front and back; and

• A completed doctor’s certificate (completed by a doctor of medicine or osteopathy) for the applicant, WH-515 (https://www.dol.gov/sites/dolgov/files/WHD/legacy/files/wh515.pdf) or applicable Department of Transportation Form, if the applicant does not have an unexpired doctor’s certificate on file with WHD.

The applicant must also list the State(s) where he or she will be driving. Note that some States have restrictions on driver’s licenses issued by foreign countries. Driving authorization will not be issued to an applicant holding only a foreign driver’s license if, at the time of filing the application, any of the listed State(s) do not accept a foreign driver’s license.

10. Certifications and authorizations

All applicants must sign the statement to affirm that the information in the application is true. A false answer or misrepresentation to any question may be punishable by fine or imprisonment. See 18 U.S.C. § 1001, 29 U.S.C. §§ 1851-1853; 29 C.F.R. § 500.6.

The applicant must sign agreeing that, if you become unavailable to accept service on a summons regarding any action taken against you, the Secretary of Labor may act as your agent and accept service on your behalf. See 29 U.S.C. § 1812(5); 29 C.F.R. § 500.45(e).

11. SUBMISSION OF APPLICATION

Send first class mail, certified mail, or 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

You may contact the Certificate Processing office by email at [email protected] or by phone at (415) 241-3505 for inquiries during the hours of 8:00am – 12:00pm and 1pm – 4:30pm Pacific Standard Time, Monday through Friday, excluding federal holidays.

Privacy Act and paperwork reduction act public burden statement

• 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.

• 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.

• 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.

• 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(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.

• Submission of this information is required under the MSPA in order to obtain the benefit of an 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 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.

• Persons are not required to respond to this collection of information unless it displays a currently valid OMB Control Number.

• 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.

WH-535

OMB# 1235-0016

Revised xx/xx/xxxx