Wh-540 Application To Amend A Farm Labor Contractor Or Farm Lab

Application to amend a Farm Labor Contractor or Farm Labor Contractor Employee Certificate of Registration, or to request a duplicate Certificate

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This application is used by Farm Labor Contractors (FLCs) and Farm Labor Contractor Employees (FLCEs) to amend a currently effective Certificate of Registration, or to request a duplicate Certificate of Registration. Please read instructions before completing this application. Please do not staple the form or any accompanying documents.

All FLCs and FLCEs seeking amendments must complete Sections 1 and 11. Only complete Sections 2 through 9 if seeking an amendment on that specific section.

If requesting a duplicate certificate because the current certificate has been lost or destroyed, complete items 1 and 10.

For companies, corporations, partnerships, limited liability companies, or other legal entities, applications for amendments will only be accepted if item 10 is signed by the applicant representative that filed the application for which amendment is requested. If the FLC needs to amend the applicant representative, go to item 3 below. For individuals or proprietorships, applications for amendments will only be accepted if item 10 is signed by the individual that filed the application for which amendment is requested.

Please complete form WH-530 if you are a FLC and do not have a current Certificate of Registration. Please complete form WH-535 if you are a FLCE and do not have a current Certificate of Registration.

1. Current certificate information: (required for all amendment or duplicate requests)

☐ Farm Labor Contractor (FLC) ☐ Farm Labor Contractor Employee (FLCE)

Current certificate number:

2. My employer has changed (FLCe Only)

Farm Labor Contractor employer name: _____________________________________________________________

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

2. The business structure has changed and The FLC is now A/An: (check one) (FLC Only)

☐Individual (with or without “Doing Business As” (DBA) name)

☐Proprietorship

☐Corporation

☐Partnership

☐Limited Liability Company

☐ Other ___________________________________

If the change in business structure resulted in the FLC being issued an EIN (Tax ID), provide the new EIN: __________________________________________

4. The Company name or the applicant representative has changed (FLC Only)

If completing this section, the FLC must provide additional documentation. See instructions for details on required documents.

Company legal name:___________________________________________­­­­_____________________

Company DBA name:___________________________________________­­­­_____________________

New Applicant Representative Information:

Note that the Applicant Representative is a person with decision-making authority for the company, such as the owner, president, CEO, etc.

First Name: ___________________________ Middle Name (Optional): ___________________

Last Name:______________________________________

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

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.

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

Read and sign the statement below if submitting Form FD-258.

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: __________________________

5. The permanent address or mailing Address has changed

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

Address:

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

Mailing or business address, if different from address above:

Address:

City: State: Zip Code: ______________ Country: _________________

Which address should appear on the certificate?

☐ Permanent place of residence ☐ Mailing / business address

6. The farm labor contracting activities to be performed have changed

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

__________________________________________________________________________________________________

7. the FLC needs to add/update transportation authorizatIon (FLC Only)

Submit proof of compliance with the motor vehicle safety and insurance requirements for EACH vehicle that you own or control to transport migrant or seasonal agricultural workers. This proof must be a completed form WH-514, WH-514a, or other substantially similar report. See instructions for further details. ☐ Attached

How will the applicant comply with the insurance or liability bond requirements? (Check all that apply.)

Attach proof of compliance for each of the vehicle insurance/liability bond options checked. See instructions for acceptable proof of compliance.

☐ 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 and sign the additional attestation.)

In what State(s) will the applicant be transporting workers? ________________________________________________________________________________

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):

_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________­­­­­­___

Section 7 continues on next page. Please complete all of Section 7.

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 or Applicant Representative:

_____________________________________________________ Date:___________________

8. the flc or flce requires Driving Authorization

Only complete if the applicant is an individual (with or without a DBA name) or proprietorship.

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)

9. the FLC needs to add or update housing authorization (FLC Only)

Check the applicable box below, and attach the corresponding document indicating that the housing that is owned or controlled by the applicant and that will be used to house migrant agricultural workers meets all applicable Federal and State safety and health standards. Such proof must be submitted for each facility or real property and must identify the specific housing (i.e., address).

☐ MSPA form WH-520, Housing Occupancy Certificate issued by a State or local health authority or other appropriate agency.

☐ Occupancy certificate or permit issued by a State or local government agency.

☐ 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.

Read and sign the following statement.

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 that has been authorized by the Secretary of Labor.

Signature: _______________________________________________ Date: ______________________________

10. The applicant requires a duplicate certificate because the current certificate is lost or has been destroyed

How was the Certificate lost or destroyed? (Attach another sheet of paper as necessary)

_________________________________________________________________________________________________

I request that the U.S. Department of Labor issue me a duplicate Certificate because my current Certificate is lost or has been destroyed.

SIGNATURE:____________________________________ DATE:

Where should the duplicate certificate be mailed?

☐ Mailing address ☐ permanent residence ☐ Temporary address (list below)

____________________________________________________________________________________________

11. CertificationS (required for all amendment requests)

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: __________________________

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: ______________________________________ 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: _____________________

WH-540 instructions for Application to amend a Farm Labor Contractor or Farm Labor Contractor Employee Certificate of Registration

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wHO should submit an application for an amendment?

This form is used by individuals and companies to apply to the U.S. Department of Labor to amend a currently effective Farm Labor Contractor (FLC) or Farm Labor Contractor Employee (FLCE) Certificate of Registration. FLC and FLCE Certificates of Registration must be amended in the following circumstances:

• Within 30 days of changing the permanent place of residence (FLCs and FLCEs);

• Within 10 days of obtaining or learning of the intended use of:

  • A property or real facility not covered by the current certificate that the FLC will own, operate, or control to house migrant agricultural workers (FLCs only); or

  • A vehicle not covered by the current certificate that that the FLC will own, operate, or control to transport migrant or seasonal agricultural workers (FLCs only); and

• Before driving workers if the current certificate does not include authorization to drive.

The applicant must also use this form to apply for an amendment for other reasons, including a change in business name, designation of additional individuals authorized to file amendment or renewal applications, and/or a change in the farm labor contracting activities to be performed.

If the applicant is seeking to file a new application or renew an existing Certificate, it should use form WH-530 (if seeking FLC registration) or form WH-535 (if seeking FLCE registration).

Purpose of Farm Labor Contractor and farm labor contractor employee registration

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 Act and are not required to register as FLCs. In addition, establishments meeting the MSPA definition of an "agricultural association" or "agricultural employer," are not required to register as FLCs.

The terms APPLICANT and APPLICANT REPRESENTATIVE are both used in this application. The APPLICANT is the entity requesting certification, and may be a company or an individual. If the APPLICANT is a company, the APPLICANT REPRESENTATIVE is a person with decision-making authority for the company, such as the owner, president, CEO, etc.

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 https://www.dol.gov/agencies/whd/contact or by phone 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 and are available here: https://www.dol.gov/agencies/whd/laws-and-regulations/laws/mspa

gENERAL iNSTRUCTIONS

All FLCs and FLCEs seeking amendments must complete items 1 and 11. Only complete items 2 through 9 if seeking an amendment on that specific item.

If requesting a duplicate certificate because the current certificate has been lost or destroyed, complete items 1 and 10.

For companies, corporations, partnerships, limited liability companies, or other legal entities, applications for amendments will only be accepted if item 10 is signed by the applicant representative that filed the application for which amendment is requested. If the FLC needs to amend the applicant representative, go to item 3 below. For individuals or proprietorships, applications for amendments will only be accepted if item 10 is signed by the individual that filed the application for which amendment is requested.

Depending upon the additional (or modified) activities, vehicles, real property, or facility for which the applicant is seeking authorization, additional forms/documentation may be necessary. Items 6 through 8 of the application will specify the name and location of the form(s) and/or a description of the specific documentation needed to amend the certificate.

Please read instructions before completing your amendment application.

1. Current Certificate information: (required for all amendment or duplicate requests)

Enter the current Certificate information. The Certificate number is located at the top left corner of the Certificate of Registration.

2. My employer has changed (FLCe Only)

Complete this section only if the FLCE is currently registered with WHD, but is switching employers. Include the information for the new employer.

3. The business structure has changed and The FLC is now A/An: (check one) (FLC Only)

Complete this section only if the applicant’s business or corporate structure has changed. For example, if the FLC was previously an individual but is now a Limited Liability Corporation, etc.

Check one box to specify the new business structure.

If the FLC was issued an EIN (tax ID) as a result of any change in business structure, list the EIN. For example, if an individual FLC operating under his or her Social Security number incorporates his or her business, he or she will be issued an EIN.

4. The Company name or applicant representative has changed

Complete this section only if the company name or applicant representative has changed.

Note that a Certificate of Registration cannot be transferred to another company or individual. Therefore, this section should only be completed if the company or individual that was issued the initial certificate remains the same, but has experienced some minor change or restructuring (e.g., change in legal name, DBA name, corporate officers, etc.).

If the company’s legal or DBA name has changed, identify the new company name exactly as it should appear on the Certificate. Attach documentation to demonstrate that the name has changed, such as registration with the Secretary of State, articles of incorporation, etc.

If the FLC is a company and the applicant representative has changed, list the new applicant representative’s information. The FLC must also provide:

• a completed FD-258 fingerprint form for the new applicant representative if it has not been provided in the previous three years; and

• corporate or other company documents demonstrating the new applicant representative’s involvement in the business (e.g., list of corporate officers, articles of incorporation, etc.),

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

5. The permanent address or mailing Address has changed

Only complete this section if the applicant or applicant representative’s permanent place of residence or mailing address has changed.

If applicable, provide the applicant or representative applicant’s NEW permanent address. This address must be for a physical location where such individual resides; it may not be a P.O. Box.

If applicable, add a mailing address (if there was none previously provided) or provide the NEW mailing address where mail can be received. If the FLC or FLCE does not normally receive mail at this address, this address should include “c/o” and provide the name of the person who the mail should be sent in care of (i.e., the person who normally receives mail at this address).

Check one box to indicate which address should appear on the certificate.

6. The farm labor contracting activities to be performed have changed

Check one box for each farm labor contracting activity to be performed. A box must be checked for each NEW activity the applicant intends to perform.

If the location of work has changed, identify the new location of work.

7. The FLC Needs to add/update transportation authorization (flc only)

Complete this section if:

• Transportation is being added as a NEW farm labor contracting activity;

• NEW vehicle(s) is/are being added to an existing transportation authorization; and/or

• The insurance policy for an existing transportation authorization has been renewed or otherwise changed.

You must attach proof of compliance with the motor vehicle safety and insurance requirements for EACH new vehicle to this application. Acceptable proof of compliance is listed below.

You must attach proof of compliance with the motor vehicle safety and insurance requirements for EACH vehicle that you own or control to transport migrant or seasonal workers to this application. Acceptable proof of compliance is listed below.

Acceptable Proof of Compliance – Motor Vehicle Safety

Each vehicle must be inspected and approved each year by a Federal or State Inspector or by a licensed, third-party garage or mechanic to ensure that it is in compliance with applicable Federal and State safety standards. Proof of compliance must be demonstrated by submitting a completed Form WH-514 (https://www.dol.gov/sites/dolgov/files/WHD/legacy/files/wh514.pdf) or Form WH-514a (https://www.dol.gov/sites/dolgov/files/WHD/legacy/files/wh514a.pdf), Vehicle Identification and Mechanical Inspection Report, or other substantially similar report. Such proof must be submitted EACH year for EACH vehicle used to transport workers.

Acceptable Proof of Compliance – Insurance or Financial Responsibility

The MSPA regulations at 29 CFR 500.120-.128 outline the insurance or financial responsibility requirements with regard to migrant and seasonal agricultural workers. These requirements are also summarized in WHD’s Fact Sheet 50 found at https://www.dol.gov/agencies/whd/fact-sheets/50-mspa-transportation. A FLC may not transport workers in any vehicle without an insurance policy or liability bond in effect. Attach proof of compliance of vehicle insurance OR liability bond requirements for EACH vehicle to this application. The applicant must check the box for the type(s) of insurance or liability bond attached to the application. The options and specific proof required are described below.

• Vehicle liability insurance coverage in the amount of not less than $100,000 for each seat in the vehicle, up to a maximum of $5,000,000 per vehicle. If checking this box, attach the certificate of insurance (and other information, as necessary) demonstrating the following information:

  • coverage limits for and effective dates of the insurance policy;

  • auto schedule or copies of separate ID cards listing the VINs for the vehicles covered. The VINs on the auto schedule and/or ID cards must match the VINs on the vehicle inspection forms; and

  • listing the “Department of Labor” and the address listed in item 12 of the instructions, below, as the certificate holder.

• Liability bond from a U.S. Department of Treasury approved “surety” assuring payment for any liability up to $500,000 for damages to persons or property arising out of transporting workers in connection with the business, activities, or operations of the person doing the transporting. If checking this box, mail the original bond to the address listed in item 12 of the instructions, below.

• 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. Applicants are responsible for consulting with their insurance companies, State workers’ compensation specialists, and/or legal counsel to ensure that all circumstances of transportation will be covered. 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.

If checking this box, attach the certificate of insurance demonstrating the workers’ compensation policy, $50,000 in insurance covering loss or damage to the property of others, and listing the “Department of Labor” and the address listed in item 12 of the instructions, below, as the certificate holder. If using workers’ compensation coverage in lieu of vehicle insurance, the applicant must also complete the following additional fields on the form:

• States in which the applicant will be transporting workers. Workers’ compensation laws vary from State to State. The applicant must ensure that it transports workers only in circumstances for which there is coverage under State law.

• List of all circumstances in which the applicant will transport workers. Some workers’ compensation policies may not cover all circumstances of transportation. The applicant is responsible for knowing what circumstances are covered by the workers’ compensation policy and transporting workers in only those circumstances.

• Affirmation that the applicant will only transport workers in circumstances covered under applicable State law. If an investigation reveals that the applicant knowingly misrepresented the circumstances in which it would transport workers, or knowingly misrepresented that such circumstances are covered under applicable State law, the Wage and Hour Division may pursue certificate revocation pursuant to MSPA Section 103(a)(1) and 29 CFR 500.51(a).

8. the applicant requires Driving Authorization

Complete this section only if the applicant is an individual or proprietorship applicant who does not have an existing driving authorization but needs to amend his/her Certificate of Registration to include driving authorization.

If applying for driving authorization, attach:

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

• completed doctor’s certificate (completed by a medical doctor or doctor of 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.

9. the applicant requires housing authorization or to add additional real properties or facilities to an existing housing authorization (FLC Only)

Complete this section if:

• Housing is being added as a NEW farm labor contracting activity;

• NEW real properties or facilities are being added to an existing housing authorization; or

• A new inspection permit has been issued.

For EACH additional facility or real property for which the applicant is requesting housing authorization, check the applicable box and attach the corresponding document indicating proof of compliance with applicable Federal and State safety and health standards. The proof may be any of the completed documents listed below, and must identify the housing (i.e., list the address).

• MSPA form WH-520, Housing Occupancy Certificate (https://www.dol.gov/sites/dolgov/files/WHD/legacy/files/wh520.pdf) issued by a State or local health authority or other appropriate agency.

• Occupancy certificate or permit issued by a State or local government agency.

• 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. The request should list the following items:

  • Property address;

  • Intended dates of occupancy;

  • Intended number of occupants;

  • Number of units (if applicable);

  • Owner of property; and

  • Printed name and signature of requesting FLC.

Sign the statement to affirm that the applicant intends to comply with the MSPA housing requirements.

10. The applicant requires a duplicate certificate because the current certificate is lost or has been destroyed

Complete this section if the applicant is requesting a duplicate certificate because the original was lost or destroyed. Identify how the certificate was lost or destroyed.

The applicant should also identify the address where the duplicate certificate should be mailed

11. Certifications

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.

All applicants must also sign the statement to affirm their intention to comply with all MSPA transportation requirements.

Finally, 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).

12. SUBMISSION OF APPLICATION

Send first class mail, certified mail, or USPS Express Mail to:

U.S. Department of Labor, Wage 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 mspaflc@dol.gov 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.

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 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.

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 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.

5. Submission of this information is required under the MSPA in 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.

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

7. 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-540

OMB# 1235-0016

Revised xx/xx/xxxx