Supplemental Information Form

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NEW JERSEY DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT
DIVISION OF WAGE AND HOUR COMPLIANCE
SUPPLEMENTAL INFORMATION FORM
To receive a New Jersey certificate of registration (provided you have already obtained a Federal Farm Labor Contractor Certificate of Registration)
you must supply the following information and be aware of the requirements listed below to comply with the New Jersey Crew Leader Registration
Act (NJSA 34:8A-7 et seq.).
APPLICANT __________________________________________________________________________________________
(Last)
(First)
(Middle)
CL
Federal Reg. No. ___________________________
SSN
AG
Address: _____________________________________________________________ Badge No. ______________________
DESCRIPTION OF VEHICLES USED TO TRANSPORT WORKERS
TYPE
YEAR
MAKE
COLOR
CAPACITY
LICENSE PLATE NO.
STATE
IN ADDITION TO ANY OTHER RESPONSIBILITIES IMPOSED BY LAW UPON THE CREW LEADER, SHE/HE SHALL COMPLY WITH THE FOLLOWING:
DISPLAY OF CERTIFICATE: All registered crew leaders and their agents shall wear and display identification badges when engaged in crew
leader activities.
An agent of the crew leader is subject to the same provisions of the law as the crew leader.
The crew leader is responsible for the activities of any agent designated by her/him.
RESPONSIBILITIES OF CREW LEADER: Notify the commissioner immediately of any change of address.
Conspicuously display at all times a hand bill (bilingual) including:
Terms and conditions of employment; Name and address of crew leader; Name and address of employer;
Date or period that employment is offered; Schematic pay schedule.
Designate an agent to accept service of summons when she/he, the crew leader, is not available.
When party to the disbursement of wages, pay workers on the same premises labor was performed immediately on termination of employment.
DISCRIMINATORY CONDUCT: Any crew leader found guilty of taking adverse action against any seasonal farm worker is liable for back
wages, exemplary damages in treble the amount of back wages, costs and attorney fees.
PENALTIES: Failure to comply with this act may result in:
Denial, suspension or revocation of a certificate of registration.
Criminal prosecution with fines up to $1,000 for each violation, or imprisonment of not more than 6 months, or both.
Civil injunctive action, or penalty of $500 for each violation.
I hereby certify that the information given above is true and accurate to the best of my knowledge and belief, and further, that I have read and
fully understand the requirements above.
________
____________________________________
________________________________________
____ ___________________
Person Issuing Certificate
Date
Signature of Applicant
Date
For additional information visit (click on Wage & Hour, then click on Registration & Permits) or contact the Vineland
(856) 238-6732 or Thorofare (856) 853-4174 One-Stop Career Centers.
SUBSTITUTE SERVICE
The following authorization is executed pursuant to Section 10(e) of the New Jersey Crew Leader Registration Act, P.L. 1975, C49 amending the
supplementing P.L. 1971, C192.
“I do hereby designate and appoint the Commissioner of the New Jersey Department of Labor and Workforce Development 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
Subscribed and sworn to me before this ___________ day of _____________________________________ 20 ________.
______________________________________
Officer administering the oath.
MW-369 (R-6-16)

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