Ca Contractors License Bond Form

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					State of California                                                             Department Of Industrial Relations
                                                               DIVISION OF LABOR STANDARDS ENFORCEMENT


                                     APPLICATION FOR
                              FARM LABOR CONTRACTOR LICENSE
      AN INCOMPLETE APPLICATION, INCLUDING INCOMPLETE SUBMISSION OF REQUIRED
   SUPPORTING DOCUMENTATION, WILL DELAY THE ISSUANCE OF YOUR LICENSE. IF YOU ARE
  SUBMITTING A RENEWAL APPLICATION, TO AVOID A LAPSE IN THE EFFECTIVE DATE OF YOUR
 LICENSE, PLEASE RETURN YOUR APPLICATION PACKAGE, WITH FEES AND DOCUMENTATION, AT
                LEAST 90 DAYS PRIOR TO THE EXPIRATION OF YOUR LICENSE.




Instructions:

1.) Please read attached Requirements and/or renewal letter and each question on the application form carefully. If a
    question does not to apply to you, put “NA” (for “Not Applicable”) on the application form for that question.

2.) Always put your license/case number on all correspondence mailed to this office.

3.) Be sure the application is signed and executed by the individual owner, all partners, or, if the business is a
    corporation, by any authorized officer. The officer’s corporate title must be shown after his or her signature.

4.) You must participate in at least eight hours of relevant education classes for each license period pursuant to the
    provisions of Labor Code section 1684(b)(2).

5.) A written examination may be required pursuant to the terms of Labor Code sections 1684(a)(5) and 1684(c)

6.) You are required to notify the Labor Commissioner of the name and address of any person or company with whom
    you enter into any contract, oral or written, to provide farm labor services at any time after issuance of your
    license.
                                      Submit the application with required fees to:

 For Counties of Kern, Tulare, Fresno, Merced,                All Other Counties:
 Kings and Madera:

 Department of Industrial Relations                           Department of Industrial Relations
 Division of Labor Standards Enforcement                      Division of Labor Standards Enforcement
 Licensing and Registration                                   Licensing and Registration
 770 East Shaw Ave., Ste. 222                                 P.O. Box 420603,
 Fresno, CA 93710                                             San Francisco, CA 94142
 559-248-1893                                                 415-703-4854



DLSE 401 (REV. 06/10)                                                                     Page 1 of 8
State of California                                                             Department Of Industrial Relations
                                                               DIVISION OF LABOR STANDARDS ENFORCEMENT

                                                REQUIREMENTS

       The items and documentation on the following list must be provided in order to complete the processing of
your application:

1.      Application fee pursuant to Labor Code section 1684(a)(4) and an examination fee pursuant to Labor Code
section 1684(b)(1). If a new applicant, $610 which includes the annual license fee, examination fee and $10 filing
fee. If a renewal applicant, $500 and an additional $100 if an exam is required pursuant to the terms of Labor Code
sections 1684(a)(5) and 1684(c). If the renewal application is received timely, the $10 filing fee may not be
required. All fees are to be paid by certified check, cashier’s check or money order payable to Division of Labor
Standards Enforcement.

2.      Live scan fingerprint images for each individual owner(s), all partners, all corporate officers and each
member of a limited liability company pursuant to forms and information provided by the Labor Commissioner.
See Attorney General’s website at www.caag.sate.ca.us/app for listing of live scan locations.

3.    Two (2) current passport photos for individual owners, all partners, one member of the limited liability
company and one corporate officer of the corporation.

4.     An original Farm Labor Contractor Surety Bond [DLSE 402 (02/06)], pursuant to Labor Code section
1684(a)(C)(3).

5.       A copy of your last year’s payroll tax filing with California EDD (DE-7 or 940 EZ).

6.      Acknowledgment that applicant has submitted to the Internal Revenue Service IRS Form 8821 (Revised
4/2004) (See form and instructions provided by the Labor Commissioner). For further information contact IRS
Taxpayer Hotline: 801-620-2400; fax 801-620-5355).

7.       A copy of Federal Certificate of Registration card issued by U.S. Department of Labor for the applicant and
for any individual employed to recruit, solicit, hire, furnish, employ or transport agricultural workers. (See
Application Question #14)

8.      A copy of Registration with the Agricultural Commissioner for each county in which you have contracted
with a grower. (For Renewals only) (See Application Question #8)

9.      Certificate of Workers’ Compensation Insurance or a certificate of self insurance issued to the applicant or a
valid contract evidencing that a third party will provide insurance. This certificate and/or documentation shall
contain the name of the legal entity, dba, if any, current physical street address, effective and expiration date,
amount of coverage and a policy number.

10.     If the applicant intends to maintain or proposes to maintain a labor camp or lodging house, evidence of its
location and a copy of a health license issued in the appropriate jurisdiction of the camp and/or lodging house. (See
Application Question #18)

11.      If the applicant will transport his/her employees and/or intends to provide transportation for farm laborers
who are not the applicant’s employees, provide information about the applicant’s liability insurance coverage for
each vehicle identified in the application, including name and address of coverage carrier, policy number, coverage
limits, including medical coverage, in an amount sufficient to afford adequate coverage of all employees transported
in the event of accident, and the policy’s effective date. (See Application Question 20)

12.     If the applicant will transport his/her employees and/or intends to provide transportation for farm laborers
who are not the applicant’s employees, a copy of the valid driver’s license for each individual who will be operating
and a copy of evidence of clear driving record from the California Department of Motor Vehicles (DMV Request
for Own Driver License or Vehicle Registration Record (INF 1125)). (See Application Question #21)


DLSE 401 (REV. 06/10)                                                                    Page 2 of 8
State of California                                                               Department Of Industrial Relations
                                                                 DIVISION OF LABOR STANDARDS ENFORCEMENT


13.      Disposition documentation: (See Application #23)

         If applicable, evidence of the disposition with a written detailed letter of explanation of any applicant,
         owner(s), all partners, managing agent(s) and/or all corporate officers listed on the Articles of
         Incorporation, Statement of Information, and/or Articles of Organization of each instance:

         a. who was cited or assessed a penalty for violating any Federal, State or local law and/or regulation,
            including any provision of the California Labor Code or health and safety regulations, or who currently
            owes or has been found to owe unpaid wages. This includes anyone serving in a key personnel capacity.
         b. who has any liens or suits pending in court against him/her.
         c. who owes payroll taxes, personal, partnership or corporate income taxes, Social Security taxes or
            disability insurance.
         d. who ever plead guilty or nolo contendere to or has been convicted of a crime, either misdemeanor or
            felony, including instances in which there was a suspension of sentence and probation granted, and
            where judicial dismissal proceedings under Penal Code Section 1203.4 and following were undertaken.
         e. who ever had any license or permit issued by any agency of the State of California suspended or revoked
            or denied to him/her or has had any disciplinary action of any nature whatever imposed upon him/her in
            connection with the holding of any such license or permit.
         f. who has ever violated or has willfully aided or abetted any person in the violation of, or failed to comply
            with, any law of the State of California regulating the employment of employees in agriculture, the
            payment of wages to farm employees, or the conditions, terms or places of employment affected the
            health and safety of farm employees, which is applicable to the business, activities, or operations of the
            licensee in his or her capacity as a farm labor contractor.



The Labor Commissioner may request any additional supporting documentation as proof of statements made in
   response to application questions and to complete his investigation to his satisfaction as to the character,
                                competency and responsibility of the applicant.




DLSE 401 (REV. 06/10)                                                                      Page 3 of 8
State of California                                                                          Department Of Industrial Relations
                                                                            DIVISION OF LABOR STANDARDS ENFORCEMENT

        Please read the attached Instructions and Requirements carefully before filling out this application
                APPLICATION FOR FARM LABOR CONTRACTOR LICENSE
1. Name of Individual or Legal Entity Applying for a License              2. Doing Business As (DBA) Name (s), if any.

3. Business Address (Number, Street, City or Town, County, State, Zip Code)                                             4. Business Telephone
                                                                                                                        ( )

5. This is an application for a    6. If Renewal, give previous license   7. Certificate of Federal Registration No. ___________
( )       New license              number.                                 (See Requirement No. 7)
( )       Renewal                  FL # _______________
8. Identification of Registration with the Agricultural Commissioner for each county in which the applicant has contracted with a
          grower (For Renewals only) (See Requirement #8)
Certificate No. ______________          County: _______________
Certificate No. ______________           County:_______________
9. Type of Ownership of Farm Labor Contractor’s Business (check one)
( ) Individual                ( ) Partnership            ( ) Corporation     ( ) Limited Liability Company           ( ) Other
_____________________________________________________________________________________________________________________

10. State and Federal Employer Identification Nos.
    SEIN: _________________
    FEIN: _________________

11. Identifying Information: On an additional sheet if needed, provide the following:
     (a) Date of Birth and Social Security Number**
     (b) If Individual Ownership – Full Name and Residence Address and Telephone Number of Owner
     (c) If Partnership - Full Names, Residence Addresses and Telephone Numbers of All Partners
     (d) If Corporation or LLC - Full Names, Titles, Residence Addresses and Telephone Numbers of All Corporate Officers,
         Managing Agents and LLC Members
     (e) AND percentage of interest of all persons, partners and associates with financial interest and/or profit sharing interest
         (excluding bona fide employees on stated salaries) in the business
     (f) For all other types of ownership, the full name, title, residence address and telephone number of all members




**Birth date: (a) If individual ownership, the individual’s birth date; (b) If partnership, the birth date of the oldest partner; (c) If
corporation, the date and state of incorporation; and (d) If Limited Liability Company, the date of organization.

12. If incorporated or organized outside California, enter the date the             13. Is corporation and LLC in good standing with
Statement and Designation by Foreign Corporation were filed with                    California Secretary of State? ( ) Yes         ( ) No
California Secretary of State

14. Will you use the services of any individual and/or entity to recruit, solicit, hire, furnish, employ, or transport agricultural
workers? (This includes foremen and crew bosses) Yes ( ) No ( ).
 If yes, has the individual and/or entity you will engage at any time in the past been issued a FLC license?     Yes ( ) No ( )
  If yes to either question above , provide the name, residence address, telephone number, social security number, and FLC license no.
 (if applicable):



15. Provide names and physical addresses, and mailing address if different, of all growers with whom you plan to contract in the
near future and/or with whom you have contracted during the past three years. Use additional sheet if needed.




DLSE 401 (REV. 06/10)                                                                                          Page 4 of 8
State of California                                                                     Department Of Industrial Relations
                                                                       DIVISION OF LABOR STANDARDS ENFORCEMENT

16. Name, address and title of person who will take examination for license       17. Preferred examination language?
(See Requirement #1)                                                                 ( ) English          ( ) Spanish


18. Do you maintain or propose to maintain a labor camp or a lodging house?
     ( ) Yes          ( ) No
If “yes”, provide exact address of location, place where license was issued and effective dates (See Requirement #10)


19. Do you sell or intend to sell intoxicating liquors (including wine or beer) on the premises where you will operate as a Farm Labor
    Contractor? ( ) Yes              ( ) No
20. Do you intend to transport your employees? ( ) Yes ( ) No (See Requirement #11)
    Do you intend to provide transportation for farm laborers who are not your employees? ( ) Yes ( ) No
    If your answer to either is “yes”, provide the name, address and telephone number of your automobile liability insurance
          carrier, policy number, coverage limits (including medical coverage) and effective dates for each vehicle used:




21. If your answer to either question in No. 20 above is “yes”, provide the name, address and drivers license number of each
individual who will operate any vehicle to provide transportation (See Requirement #12)



    AND complete the information for each vehicle used on Attachment A hereto.


22. Will the Farm Labor Contractor's operation be conducted in connection with any other business? ( ) Yes             ( ) No
    If yes, give type of business and name and address of business.


23. Does/has any person named in Question 11:
    (a) Owe any unpaid wages?                                                                                           (   )   Yes   (   )   No
    (b) Have any unpaid judgments outstanding                                                                           (   )   Yes   (   )   No
    (c) Have any liens or suits pending in court against him/her?                                                       (   )   Yes   (   )   No
    (d) Owe payroll taxes, personal, partnership or corporate income taxes, Social Security taxes or disability         (   )   Yes   (   )   No
        insurance?
    (e) Ever been cited or assessed any penalty for a violation of any Federal, State or local law and/or               ( ) Yes       ( ) No
        regulation, including any provision of the California Labor Code or health and safety regulations?              ( ) Yes       ( ) No
    (f) Ever plead guilty or nolo contendere to or been convicted of a crime, either misdemeanor or felony?
        (Note: The term convicted includes instances in which there was a suspension of sentence and
        probation granted, and where and where judicial dismissal proceedings under Penal Code Section
        1203.4 and following were undertaken)                                                                           ( ) Yes       ( ) No
    (g) Ever had any license or permit issued by any agency of the State of California suspended or revoked
        or denied to him/her or has any disciplinary action of any nature whatsoever ever been imposed
        upon his/her in connection with holding of any such license or permit?
                                                                                                                        ( ) Yes       ( ) No
    (h) Ever violated or willfully aided or abetted any person in the violation of, or failed to comply with, any 
        law of the State of California regulating the employment of employees in agriculture, the payment of 
        wages to farm employees, or the conditions, terms or places of employment affected the health and 
        safety of farm employees, which is applicable to the business, activities, or operations of the licensee in 
        his or her capacity as a farm labor contractor.

If “yes” to any of the above, on an additional sheet, provide an explanation of circumstances and provide
documentation as required in Requirement No. 13.
24. Name and address of Agent/Representative designated to speak on your behalf.




25. (Intentionally left blank)




DLSE 401 (REV. 06/10)                                                                               Page 5 of 8
State of California                                                                    Department Of Industrial Relations
                                                                      DIVISION OF LABOR STANDARDS ENFORCEMENT

                                                         CERTIFICATIONS


I am/We are aware of and agree to comply with the provisions of Section 3700 of the Labor Code which require every employer to
be insured against liability for workers' compensation.

I am/We are aware of and agree to comply with the provisions of Section 1684(a) (3) to deposit with the Labor Commissioner and
maintain a current surety bond.

I/We agree, in the event that transportation is provided for employees, to carry public liability insurance on each vehicle used, as
required by Section 1695(6) of the Labor Code and to ascertain that all individuals providing transportation are legally licensed and
competent to transport employees.

I/We agree that as a condition of being licensed as a Farm Labor Contractor by the Labor Commissioner of the State of California, it
is my/our responsibility to keep the Commissioner informed of any change in my/our address(es).

I/We consent, pursuant to Labor Code Section 1684(a)(1)(C), to the designation of the Labor Commissioner by an appropriate civil
court as my agent to accept service of summons in any action against me/us relating to my/our activities as a licensed Farm Labor
Contractor in the event that I/we have left the jurisdiction in which the action is commenced or have otherwise become unavailable
to accept service.

I am/We are aware of the responsibilities as licensee and agree to operate as a farm labor contractor in compliance with the
provisions of the California Labor Code, including provision of adequate safeguards for health and safety of workers, and certify
that I/we have provided all facts required by the Labor Commissioner to make its determination to issue a license to operate as a
Farm Labor Contractor as to my/our character, competency, responsibility and the manner in which I/we propose to conduct
operations.

I am/We are aware of the provisions of the Labor Code regarding the grounds for revocation, suspension, refusal to renew and/or
issue a license to operate as a Farm Labor Contractor.

I/We hereby certify, under penalty of perjury, that the foregoing statements are true and correct. I/We are aware of the fact that

ANY MATERIAL MISREPRESENTATION IS GROUNDS FOR DENIAL, OR SUBSEQUENT REVOCATION OF A LICENSE.

Executed at ___________________________, California, this ______________ day of _________________ 20 ________.

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.)


___________________________________________________            _________________________________________________________



____________________________________________________            _________________________________________________________

* 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.




DLSE 401 (REV. 06/10)                                                                               Page 6 of 8
State of California                                     Department Of Industrial Relations
                                       DIVISION OF LABOR STANDARDS ENFORCEMENT


ATTACHMENT A:


V     Name and Address of Owner   Make and Year                   Body Type & Capacity
E
H
I
C                                 Motor or Serial No.             Vehicle License No.
L
E
#1
V     Name and Address of Owner   Make and Year                   Body Type & Capacity
E
H
I
C                                 Motor or Serial No.             Vehicle License No.
L
E
#2
V     Name and Address of Owner   Make and Year                   Body Type & Capacity
E
H
I
C                                 Motor or Serial No.             Vehicle License No.
L
E
#3
V     Name and Address of Owner   Make and Year                   Body Type & Capacity
E
H
I
C                                 Motor or Serial No.             Vehicle License No.
L
E
#4
V     Name and Address of Owner   Make and Year                   Body Type & Capacity
E
H
I
C                                 Motor or Serial No.             Vehicle License No.
L
E
#5
V     Name and Address of Owner   Make and Year                   Body Type & Capacity
E
H
I
C                                 Motor or Serial No.             Vehicle License No.
L
E
#6




DLSE 401 (REV. 06/10)                                          Page 7 of 8
State of California                                                         Department Of Industrial Relations
                                                           DIVISION OF LABOR STANDARDS ENFORCEMENT

                                    DO NOT WRITE BELOW THIS LINE
Application Number      B           F/C                      Amount     Date Received   Date Issued   Date Mailed
                        P/R         P/L
                        A/C         WCI
Approved State                              License Fees
                        F/R#        EXAM
Labor Commissioner      IRS         D/F     License Fees
                        INC         DL
                        8 HR        TIPP    Refund
                        Photos      Name
                        DE7      match ID
                        CO. AG
                        SOI
                        FLCE




DLSE 401 (REV. 06/10)                                                              Page 8 of 8

				
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