Farm Labor Contractor Short-Form License Renewal Application (Page 2 of 3) in pdf

A current list containing the name, physical address, and mailing address if different, of each grower with whom you

plan to contract in the near future and/or with whom you have contracted during the past three years.

A list which states the name, physical address, and position title of all individuals or other entities (other than an

independent contractor) employed in the previous calendar year to act on behalf of the applicant’s business to recruit,

solicit, hire, supply, employ, furnish board, lodging, or transport for agricultural workers, supervise or otherwise direct the

work, or disburse wage payments to agricultural workers on behalf of the applicant’s business which includes but is not

limited to, foremen and crew bosses.

A list containing the full name and physical home address of all individuals employed by the applicant who the applicant

knows have previously applied for a state farm labor contractor license and were denied that license, or who have been, at

any time, licensed by the state as a farm labor contractor, and who will be employed by you to perform any of the

following: supervise, recruit, solicit, hire, employ, furnish board, lodging, or transport for agricultural workers, supervise

or otherwise direct the work or disburse wage payments to agricultural employees. The federal farm labor contractor

Certificate of Registration number issued by the U.S. Department of Labor and the state farm labor contractor (FLC)

license number for each of these individuals shall also be provided.

A current list of the full names of any of the relatives listed in section 13660(a)(17) who the applicant knows has

previously applied for or held an FLC license and have been denied or had their license revoked within the last 10 years.

A copy of your current federal certificate of registration card (issued by the U.S. Department of Labor), if required

under federal law, and a copy of each federal Certificate of Registration issued by the Department of Labor for any

employee of the applicant if the employee is required to register under the Migrant and Seasonal Worker Protection Act

(29 U.S.C. section 1801 et seq.).

10. Two (2) current passport photos for sole proprietorship, all partners, one member of the limited liability company and

one corporate officer of the corporation, as applicable for the type of the business entity.

11. Acknowledgment that applicant has submitted IRS form 8821 to the Internal Revenue Service. For further information

contact IRS Taxpayer Hotline: (801) 620-2400; Fax (855) 235-8843.

12. A copy of your last year’s quarterly payroll and contribution filings with California EDD (DE-9, DE-9C, and DE-

9ADJ,if applicable), as specified in Title 8, California Code of Regulations, section 13661(b)(2)(C)(xi)).

13. A copy of your most current registration with the agricultural commissioner for each county in which you have

contracted with a grower.

14. A copy of any completion certificate(s) showing nine (9) hours of relevant educational classes for each license period

pursuant to the provisions of Labor Code section 1684(b)(2).**

15. A current statement which includes the name, address, telephone number, and qualifications for each individual, who will

provide training in identification, prevention, and reporting of sexual harassment in the workplace, as required by Labor

Code section 1684(a)(8).

16. Signed Farm Labor Contractor Supervisory Employee Sexual Harassment Disclosure Statement for each employee of the

applicant whose duties include the supervision, direction, or control of agricultural employees.

FLC License Number

Applicant Name(s):

__________________________________________________________________________

Business Name(s):

__________________________________________________________________________

Physical Business Address: __________________________________________________________________________

Preferred Mailing Address:

__________________________________________________________________________

Home Address (No PO Box allowed):____________________________________________________________________

Business Telephone:

__________________________________________________________________________

Mobile Telephone:

_________________________ Preferred Email Address: ____________________________

Number of Employees:

__________________________________________________________________________

Total Gross Annual Revenue:__________________________________________________________________________

I hereby certify, under penalty of perjury, that the foregoing statements are true and correct. Additionally, I/we attest that all

supervisorial employees, including supervisors, crewleaders, mayordomos, forepersons, and any others whose duties include the

supervision, direction, or control of agricultural employees have been/will be trained for at least two hours each calendar year in the

prevention of sexual harassment in the workplace and that all new non supervisorial employees, including agricultural employees,

have been/will be trained at the time of hire and that all nonsupervisory employees have or will receive training in identifying,

preventing, and reporting sexual harassment in the workplace at least once every two years. The certifications and

acknowledgements made in my initial or most recent regular renewal application still apply. I further certify under penalty of

perjury that there are no changes to my previous application and that I meet the four conditions required for this short form license

renewal application in Title 8 of California Code of Regulations section 13661(b)(1)(A)-(C). I understand that ANY MATERIAL

MISREPRESENTATION IS GROUNDS FOR DENIAL OR SUBSEQUENT REVOCATION OF THIS APPLICATION.

SIGNATURES: (The individual owner or all partners must sign. If business is a corporation or limited liability company, any

authorized corporate officer or member, with indication of title, may sign.)

DLSE 401-S (Rev. 01/2015)

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Farm Labor Contractor Short-Form License Renewal Application Page 2

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