Form Wh 530 PDF Details

Navigating the intricacies of agricultural employment and legal compliance, the WH-530 form emerges as a crucial document for those seeking to serve as Farm Labor Contractors (FLC) or Farm Labor Contractor Employees (FLCE) under the Migrant and Seasonal Agricultural Worker Protection Act. This comprehensive form, mandated by the U.S. Department of Labor's Wage and Hour Division, requires meticulous completion by all applicants aiming to obtain or renew their certificate of registration. It covers a broad spectrum of information, from personal identification and legal status to details about the services provided, such as hiring, transporting, or housing migrant and seasonal agricultural workers. Additionally, it delves into the applicant's legal background, driving and insurance compliance for transporting workers, and adherence to health and safety standards for any provided housing. This form not only serves as an application but as a declaration of the applicant's intent to comply with all federal and state regulations concerning the safety, compensation, and wellbeing of agricultural workers. With its expiration date carefully noted, the form acts as a testament to the commitment of the Department of Labor to uphold the rights and protections afforded to one of the most vital sectors of the workforce. The careful completion and submission of this form signify the first step in ensuring ethical and legal farm labor contracting practices.

QuestionAnswer
Form NameForm Wh 530
Form Length8 pages
Fillable?No
Fillable fields0
Avg. time to fill out2 min
Other nameslabor workers application, labor registration application, form application farm, labor certificate farm

Form Preview Example

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

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: (Check only one)

FLC

 

 

 

Initial

 

 

 

Renewal

 

 

 

Amended

FLCE

 

 

 

Initial

 

 

 

Renewal

 

 

 

Amended

 

 

 

 

 

 

 

 

 

If renewal, Prior Certificate Number:

 

 

 

 

 

 

 

 

 

 

 

 

Is form FD-258 fingerprint card attached?

Yes

____

No

____

(See Instructions)

 

 

 

 

 

 

 

 

 

 

 

 

2. Name of applicant or applicant’s representative (Please Type or Print)

e

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Last)

 

 

 

 

 

 

 

 

 

 

 

 

(First)

 

 

 

 

 

 

 

 

(Middle)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Permanent place of residence (Address May Not Be a P.O. Box):

 

 

 

 

 

 

Street:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City:

 

 

 

 

 

 

 

 

 

 

State:

 

 

 

 

 

Zip Code:

 

Country:

 

 

 

 

 

 

 

 

 

 

If mailing address is different, please complete the following

 

 

 

 

 

 

(Address May Be a P.O. Box):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Street:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City:

 

 

 

 

 

 

 

 

State:

 

 

 

 

 

 

 

 

 

Zip Code:

 

 

 

 

 

 

Country:

 

 

 

 

 

 

 

 

Primary

Telephone

Number:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Alternate telephone:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Social Security Number:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3. Sex: Male

 

 

 

 

 

 

Female

 

 

 

 

 

 

 

 

 

 

lbs.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Height:

 

 

 

 

ft.

 

 

 

 

 

in

Weight:

 

 

 

 

 

 

 

 

 

Eye color:

 

 

 

 

 

 

 

 

 

 

Hair color:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4.Date of birth (mo., day, year):

United States citizen:

 

 

 

Yes

 

 

 

No

If naturalized citizen, provide date:

If visa holder, provide visa no. or temporary worker visa no.:

Visa expiration date (If applicable):

5.Driving authorization: (To be completed by an “individual” applicant)

Will you drive a vehicle to transport workers?

 

 

 

Yes

 

No

If “yes”, read instructions and complete the following:

Driver’s license no.:

(Attach copy of license to application)

State:

 

Date issued:

 

 

 

Expiration date:

 

 

Class:

 

 

 

Endorsements:

 

 

 

 

 

 

 

Restrictions:

 

 

 

 

 

 

 

A valid doctor's certificate must be submitted every three years.

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?

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 “Yes,” to a CONVICTION of any of the above, attach a copy of the final judgment 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.)

FormWH-530

OMB No. 1235-0016

Expires 08/31/2023

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.

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)

Applicant name to appear on certificate (for example, legal name of corporation or doing business as / dba) (Area code) (Number)

If the applicant has submitted any other applications under a different name(s), provide the names here

Business address to be listed on certificate (if different from the permanent place of residence in Item 2)

(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:

 

 

 

 

 

Hire

 

Furnish

 

Transport

 

 

Solicit

 

 

 

 

 

 

 

 

 

 

 

Recruit

 

 

Employ

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

9.

Give the greatest number of migrant and/or seasonal agricultural workers that will be in the crew(s) at any time:

 

 

 

 

 

 

 

 

 

 

 

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?

____ No. Explain how workers will get to the worksite:

 

 

 

Yes. Number of Workers:

 

Type of vehicle(s) and seating capacity:

 

 

 

 

 

 

 

 

 

 

If “No,” proceed to Item 11. If “Yes,” answer the questions below:

 

 

 

 

 

 

 

 

 

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

 

 

 

 

 

 

 

 

 

Yes

 

 

No

 

 

 

 

 

No. Is a properly completed WH-514a Vehicle Mechanical Inspection Report attached for each vehicle?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(item 10 continues on next page)

Page 2

– Continued on Next Page –

10.continued

How will the applicant comply with the insurance or liability bond requirements? (Check all that apply and attach proof of compliance for each of the vehicle insurance or liability bond options listed below.)

☐Vehicle liability insurance coverage in the amount of not less than $100,000 for each seat in the vehicle.

☐Liability bond.

☐State workers’ compensation insurance coverage and a minimum of $50,000 per accident in motor carrier or other appropriate insurance covering loss or damage to the property of others (excluding cargo). The workers’ compensation policy must cover all circumstances in which the migrant or seasonal agricultural workers will be transported or, if necessary, additional coverage through a liability insurance policy or liability bond must be procured for transportation not covered by the State law. (If using workers’ compensation coverage in lieu of vehicle insurance, the applicant must complete the following additional questions.)

If using state workers’ compensation insurance coverage in lieu of vehicle insurance, check all circumstances in which the applicant will transport workers and sign below:

☐Daily transportation between living quarters and worksite

☐Recurring transportation to run errands (e.g., to the grocery store, laundromat, etc.)

☐Long distance travel between worksites, or to/from the worker’s permanent residence in a different city, state, or country

☐Other (describe):

________________________________________________________________________________________________

________________________________________________________________________________________________

____________________________________________

I affirm that I have truthfully listed all circumstances in which I will transport workers, and that my workers’ compensation policy covers these circumstances under applicable State law. I further affirm that I will not transport workers in any circumstances not covered under applicable State law by my workers’ compensation policy.

SIGNATURE OF APPLICANT:

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 control housing to be used by

applicable Federal and State safety and health

 

migrant agricultural workers in the crew.

standards.

 

 

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

Page 3

– Continued on Next Page –

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 _________________________

Statement of Intention to Comply with Transportation Requirements of the Migrant and Seasonal Agricultural Worker Protection Act (MSPA)

When using, or causing to be used, any vehicle for providing transportation to migrant and/or seasonal agricultural workers, I declare that I will ensure that each vehicle conforms to applicable Federal and State safety regulations, that it has an insurance policy or liability bond in effect which insures me against liability for damage to persons or property arising from transporting any migrant or seasonal agricultural workers in that vehicle, and that each driver has a valid and appropriate license, as provided by State law, to operate the vehicle. I further declare that I will not transport migrant or seasonal agricultural workers in any vehicle I own or control until I have submitted all necessary written evidence and have been issued a Certificate of Registration with transportation authorized, and that I will maintain the vehicle(s) in accordance with applicable Federal and State safety regulations, maintain insurance at the required levels, and transport only in circumstances that are covered by my insurance.

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

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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.):

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

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 5

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Part number 1 in filling out labor migrant u

2. The next step is usually to fill in all of the following fields: Alternate telephone, Social Security Number, Sex Male, Female, Height, ft in, Weight lbs, Eye color, Hair color, Date of birth mo day year, United States citizen, Yes, If naturalized citizen provide date, If visa holder provide visa no or, and Visa expiration date If applicable.

labor migrant u conclusion process detailed (step 2)

Be really careful while filling out If naturalized citizen provide date and Weight lbs, because this is where a lot of people make a few mistakes.

3. Completing The applicant is aan Check One, Individual, Corporation, Partnership, Other Specify, Applicant name to appear on, Area code Number, If the applicant has submitted any, Business address to be listed on, Street, Date of incorporation, City, State, Zip Code, and IRS employer identification No is essential for the next step, make sure to fill them out in their entirety. Don't miss any details!

The applicant is aan Check One, Street, and Zip Code in labor migrant u

4. This next section requires some additional information. Ensure you complete all the necessary fields - Will you be directly transporting, No Explain how workers will get, Yes Number of Workers, Type of vehicles and seating, If No proceed to Item If Yes, Will any single trip be more than, Yes Is a properly completed WH, Yes, No Is a properly completed WHa, Yes, item continues on next page, Page, and Continued on Next Page - to proceed further in your process!

The right way to fill in labor migrant u step 4

5. The very last notch to conclude this form is integral. Be certain to fill in the mandatory form fields, which includes Vehicle liability insurance, Liability bond State workers, appropriate insurance covering, If using state workers, Daily transportation between, and I affirm that I have truthfully, prior to finalizing. Or else, it could produce an incomplete and possibly nonvalid form!

If using state workers, I affirm that I have truthfully, and Daily transportation between in labor migrant u

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