Form WH-530 "Application for a Farm Labor Contractor or Farm Labor Contractor Employee"

What Is Form WH-530?

This is a legal form that was released by the U.S. Department of Labor - Wage and Hour Division on November 1, 2015 and used country-wide. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on November 1, 2015;
  • The latest available edition released by the U.S. Department of Labor - Wage and Hour Division;
  • Easy to use and ready to print;
  • Yours to fill out and keep for your records;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form WH-530 by clicking the link below or browse more documents and templates provided by the U.S. Department of Labor - Wage and Hour Division.

ADVERTISEMENT
ADVERTISEMENT

Download Form WH-530 "Application for a Farm Labor Contractor or Farm Labor Contractor Employee"

456 times
Rate (4.4 / 5) 21 votes
Application for a Farm Labor Contractor or
U.S. Department of Labor
Farm Labor Contractor Employee
Certificate of Registration
Migrant and Seasonal Agricultural Worker Protection Act
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 only one
(Attach copy of license to application)
Is form FD-258 fingerprint card attached?
See Instructions
(Please Type or Print)
e
(Last)
(First)
(Middle)
A valid doctor's certificate must be submitted every three years.
(Address May Not Be a P.O. Box)
(Address May Be a P.O. Box)
5
(mo., day, year)
CONVICTION
attach a copy
of the final judgment
e
(If applicable)
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
Page 1
– Continued on Next Page –
REV 11/2015
Application for a Farm Labor Contractor or
U.S. Department of Labor
Farm Labor Contractor Employee
Certificate of Registration
Migrant and Seasonal Agricultural Worker Protection Act
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 only one
(Attach copy of license to application)
Is form FD-258 fingerprint card attached?
See Instructions
(Please Type or Print)
e
(Last)
(First)
(Middle)
A valid doctor's certificate must be submitted every three years.
(Address May Not Be a P.O. Box)
(Address May Be a P.O. Box)
5
(mo., day, year)
CONVICTION
attach a copy
of the final judgment
e
(If applicable)
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
Page 1
– Continued on Next Page –
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 submitted any other applications under a different name(s), provide 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 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:
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 for each 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?
Submit statement identifying all housing to be
Give the name and address of all persons
Yes.
No.
used and proof that such housing meets all
who own or control housing to be used by
applicable Federal and State safety and health
migrant agricultural workers in the crew.
standards.
Page 2
– Continued on Next Page –
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
and Date
(if other than individual)
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
Date
Page 3
– Continued on Next Page –
PART III – To Be Completed by Any Applicant for a
Farm Labor Contractor Employee (FLCE) Certificate of Registration
12. Employer Identification (
:
13. Approximate Date the Planned Farm
Name, Farm Labor Contractor Registration No.)
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
Page 4
– Continued on Next Page –
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.
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 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.
Page 5
– Continued on Next Page –
Page of 7