Fillable Printable Form WH-530
Fillable Printable Form WH-530
Form WH-530
ApplicationforaFarmLaborContractoror
Farm Labor Contractor E mployee
Certificate of Registration
MigrantandSeasonalAgricul turalWorkerProtectionAct
U.S. Department of Labor
OMB NO: 1235-0016
Expires: 11/30/2018
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.).
Check onlyone
Is form FD-258 fingerprint card attached?
See Instructions
(Please Type or Print)
e
(Last) (First) (Middle)
(Address May Not Be a P.O.Box)
(Address May Be a P.O. Box)
(mo., day, year)
e (If applicabl e)
(Attach copy of license to application)
A valid doctor's c ertifi cat e must be submitted every three years.
CONVICTION
attach a copy
of the final judgment
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.
Form WH-530
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REV 11/2015
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)
( )
Name of applicant
(or legal name of corporation, and doing business as / dba) (Area code) (Number)
If the applicant has submitt ed any other appli cations under a different name(s), provid e the names here
Name of representative for purposes of this application
(Street) (City) (State) (Zip Code)
Date of incorporation: IRS employer identification No.:
State of incorporation: State unemployment insurance reportingno.:
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:
(Month, Day, Year)
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?
Yes. Number of Workers: Type of vehicle(s) and seating capacity:
Will any single trip be more than 75 Miles round-trip?
Yes. Is a properly completed WH-514 Vehicle Mechanical Inspection Report attached foreach vehicle? Yes No
No. Is a properly completed WH-514a Vehicle Mechanical Inspection Report attached for each vehicle? Yes No
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.
No. Explain how workers get to the worksite
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
No.
Give the name and address of all persons
used and proof that such housing meets all who own or contro l housing to be used by
applicable Federal and State safety and health
migrant agricultural workers in the crew.
standards.
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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
Migran t and S eason al Ag ricu ltural Worker Protect ion A ct (MSPA)
Section 102(3) of the MSPArequires 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 sho wing that the applica nt is in compliance with all substantive Feder al and State safety and health
standards with respect to each such facil ity or real property. I hereby declare t hat 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 LegalProcess
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 summ ons in any action against m e 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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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 f arm labor contractor identif i ed above and will perf orm f arm 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 summ ons in any action against m e 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).”
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) Certificateof 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 Certifi cat e 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 initi al certi f i cate, attach a com pleted Form FD-258,
Fingerprint Card, to this application. If applying for a renewal certificate and your last Fingerprint Card is mor e 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 – 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 M edi cal Examiner's Certificate or the DOT Form 64 9-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 bu siness, activities, or operations as a farm labo r contractor shall be is sued only after the f ol l owing
have beensubmitted:
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 furnis h 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 compl eted Form WH-514 or WH-514a, Vehicle Identification and
Mechanical Inspection Report, must be submitted to the U.S. Department of Labor ea ch 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 p roperty when the con tractor is in charge of or h as t he power or authority t o oversee, manage,
superintend, or admi ni st er facilities or real prop ert y 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 i n the name in which your empl oyer’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 13-100
San Francisco, CA 94103
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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 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 Departme nt of Labor using this coll ection of inform ation in the FLC/FLCE regi st rat ion process,
i
nformation from this form may be used in the course of presenting evidence to a court of administrative tribunal or i
n
t
he 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 I
nformation 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.
Th
e Department of Labor makes no express assurances of confidentiality regarding this collection of informati
on.
5.
Submission of this information is required under the MSPAin order to obtain the benefit of a FLC or FLCE Certificate
o
f Registration. 29 U.S.C. §§ 1811-1812; 29 C.F.R. § 500.44-.47. Unlawfully engaging in FLC activities without
a
v
alid 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
N
umber
.
7.
The Department of Labor estimates that it will take an average of 30 m inutes to complete this collection of
i
nformation, including the time for reviewing instructions, searching existing data sources, gathering and maintaini
ng
t
he data needed and completing and reviewing the collection of information. If you have any suggestions for reduci
ng
this burden, send them to the Administrator, Wage and Hour Division, Room S-3502, 200 Constitution Avenue, N.W.,
W
ashington, DC 202
10.
D
O NOT SEND THE COMPLETED FORM TO THIS OFFICE, SEND TO THE ADDRESS APPEARING ON
PAGE 6 OF THIS FORM.
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