Application for a Farm Labor Contractor or

Farm Labor Contractor Employee Employment Standards Administration 

Certificate of Registration Wage and Hour Division

Migrant and Seasonal Agricultural Worker Protection Act 

NOTE: Persons are not required to respond to this collection of information unless it displays a currently valid 

OMB control number. 

OMB No. 1215-0037 

Expires: 08-31-06

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.) 

1. Application for Certificate of Registration for: 4. Give Address to Which Notices and Documents Should Be 

Sent (Address may include a P.O. Box): 

Federal Initial Renewal 

Street: 

Consolidated Federal-State Initial Renewal 

Type of Certificate: FLC FLCE City: 

2. Person Completing Application: (Please Print) 5. Will You Drive a Vehicle to Transport Workers? 

(To be completed by an ''Individual'' applicant) 

No Yes If "Yes," Read Instructions 

and Complete the Following: Name (Last) (First) (Middle) Driver's License No.: 

(Attach copy of license to application) 

Permanent Place of Residence (Address May Not Be a P.O. Box): State: 

Date Issued: Street: 

Expiration Date: 

City: State: Class: Endorsements: 

Restrictions: 

Telephone Number: Social Security Number:

/ / / /-/ / /-/ / / / / 

3. Height: ft. in. Color of Eyes: 6. Have you been convicted within the past 5 years, under 

State or Federal law, of any of the following crimes? 

Sex: Male Female 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.

Date of Birth (Mo., Day, Year): 

Yes No

B. Any felony involving robbery, bribery, extortion, em- (a) United States Citizen: Yes No (if No, Go to (b)) bezzlement, 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. 

If naturalized citizen, give date: 

(b) Alien Registration No.: Yes No 

(Attach copy of card to application) 

(If ''Yes," to a CONVICTION of any of the above, state 

crime and give date and place of conviction.) Attach 

copy of final judgment in the case to the application, if in 

your possession. 

Expiration Date (If any): 

( ) 

A false answer or misrepresentation to any question may be punishable by fine or 

imprisonment (U.S. Code, Title 18, Sec. 1001). 

Form WH-530 

Rev. June 1998 

ZIP code:

U.S. Department of Labor

State: ZIP Code:
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, Address, Telephone Number, Date and State of Incorporation. (Please Print) 

Name of Applicant (Legal Name of Corporation) (Area Code) (Number) 

(Street) (City) (State) (ZIP Code)

Date of Incorporation: Social Security Employer Identification No.

(if None, Enter "None") 

State of Incorporation: State Unemployment Insurance Reporting No.

(If None, Enter "None") 

Recruit Hire Furnish Transport

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) 

Describe your method of operation (Specify crops, agricultural activity, places of employment, location, etc.): 

10. Will You Provide Transportation for Your Workers? 

Yes (Give number, type and seating capacity of vehicles used to transport migrant and seasonal agricultural workers.) 

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 No (Give the name and address of all persons who

own or control housing to be used by Migrant 

Agricultural Workers in the crew.) 

and proof that such housing meets all applicable 

Federal and State safety and health standards.) 

( ) 

8. Check Each Activity to Be Performed Involving Migrant and/ or Seasonal Agricultural Workers for Agriculture Employment: 

Solicit Employ Pay
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) 

Statement of Intention to Comply with Housing Requirements of 

the Migrant and Seasonal Agricultural Worker Protection Act 

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. 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 

Authorization of the Secretary of Labor to Accept Legal Process 

The following authorization is executed pursuant to Section 102(5) of the Migrant and Seasonal Agricultural Worker 

Protection Act. 

''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 
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.): 

Name: 

Number: C-/ / /-/ / / / / / /-/ /-/ / /-/ / 

13. Approximate Date the Planned Farm 

Labor Activity Will Begin: 

(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 

Authorization of the Secretary of Labor to Accept Legal Process 

The following authorization is executed pursuant to Section 102(5) of the Migrant and Seasonal Agricultural Worker 

Protection Act. 

''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 
Instructional and Information Guide for 

Applying for a Certificate of Registration 

For Further Details, Refer to the Regulations (29 CFR, Part 500) and to the U.S. Department of Labor

Publication, ''Migrant and Seasonal Agricultural Worker Protection Act.'' 

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 Farm

Labor Contractor Certificate of Registration. Part III is to be completed only by applicants applying

for a Farm Labor Contractor Employee Certificate of Registration. 

Item 1 - Application for certificate. 

Federal - Check this block when applying only for a Federal Certificate of Registration. 

Consolidated Federal-State - Check this block when applying for both a Federal and State Certificate 

of Registration. This option is not available in every State. For further information, contact the local 

Employment Service Office. 

If no Farm Labor Contractor or Farm Labor Contractor Employee (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 a certificate has been issued to you by the

U.S. Department of Labor, check "renewal'' and enter the number of the last certificate issued to you. 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. 

Type of Certificate - Check one block to indicate whether applying as a Farm Labor Contractor (FLC) or

as a Farm Labor Contractor Employee (FLCE). 

Item 2 - Person making application. This item is to identity 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. 

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 Farm Labor Contractor 

Certificate of Registration or a Farm Labor Contractor Employee Certificate of Registration prior to

so engaging in farm labor contracting activities. 
Item 8 - For a definition of "employ," see 29 CFR 500.20 (h) (4). 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: 

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, as

follows: 

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 the

passenger hazard included (i.e., workers are covered by liability insurance while being

transported) as evidence that the required insurance has been obtained for the protection of

persons and their property 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 Act 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. 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. 
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 property 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 Statement 

The Privacy Act of 1974 requires that the Department of Labor provide the following statements with

respect to this form: 

1 . Submission of this information is required under the Migrant and Seasonal Agricultural Worker Protection 

Act. 

2. The purpose of this form is to provide the Department of Labor with sufficient information to determine

the qualifications of the applicant for the requested certificate to serve as a Farm Labor Contractor 

employee. 

3. Information from this form may be used in the course of presenting evidence to a court or administrative 

tribunal or in the course of settlement negotiations. 

4. 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 title 

29 of the Code of Federal Regulations, Part 500. 

Public Burden Statement 

We estimate 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 comments regarding

this burden estimate or any other aspect of this collection of information, including suggestions for reducing

this burden, send them to the Administrator, Wage and Hour Division, Boom S-3502, 200 Constitution

Avenue, N.W., Washington, DC 20210. DO NOT SEND THE COMPLETED FORM TO THIS OFFICE.