Farm Labor Contractor Short-Form License Renewal Application Page 3
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Signature
Print Name & Title
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Signature
Print Name & Title
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Signature
Print Name & Title
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Signature
Print Name & Title
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Signature
Print Name & Title
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* If place of execution is outside California, the foregoing statements must be sworn to before a notary public or other officer
authorized to take oaths and affirmations.
** Labor Code 1684(c) was amended to require applicants for a Farm Labor Contractor License take nine (9) hours of continuing
education per year beginning January 1, 2015. Completion certificates showing eight (8) hours of continuing education that was
completed in 2014 will be accepted as satisfaction of the continuing education requirement for applications presented to DLSE through
December 31, 2015. Completion certificates for continuing education completed on or after January 1, 2015 must indicate completion of
nine (9) hours of continuing education to be accepted as satisfying the continuing education requirement for new and renewal
licenses.
DLSE 401-S (Rev. 01/2015)
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