Application for a Farm Labor Contractor Illinois by ukw21947


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									State of Illinois
Illinois Department of Labor

Contractor Application for a Farm Labor Identification Card
                                                                                 Submit by Email               Print Form

                                                                                                                                     File Number
Application for Identification Card:

  Illinois Department of Labor              Initial        Renewal     Last ID number:                                 Change
  Fair Labor Standards Division
  Michael A. Bilandic Building
  160 North LaSalle, Suite C-1300      Name:
  Chicago, Illinois 60601-3150
  Tel # (312) 793-2804                 Permanent
                                                          Street Address:
  Fax# (312) 814-1210                  Home
  Social Security #
                                       City:                                      State:        Zipcode:
  Telephone #
                                       Address for sending notices and documents, if different from Permanent Address
       Other #

                                                                                                                                     Reviewed By:

  Date of Birth:                       City:                                      State:        Zipcode:

  Are you a full-time regular employee of a corporation, partnership, association or other            Yes               No
  organization engaged in any activities covered by this Act?
            Names and addresses of all people financially interested in the Farm Labor Contractor operation:

 Home Address:

            City:                                                      State:        Zipcode:

                                                                                                                                     Date Received

Home Address:

            City:                                                       State:       Zipcode:


 Home Address:

            City:                                                      State:        Zipcode:

Are you, or have you been convicted of a felony, filed bankruptcy, or currently the                  Yes                No
defendent in any civil litigation? If yes, please explain on an additional sheet of paper.
Will any form of transportation be provided? If yes, a copy of your current certificate
                                                                                                     Yes                No
of Insurance must be included with your application.
I certify that the above information is true to the best of my knowledge and belief and            Digital Signature
 that any false answer or misrepresentation is punishable by fine and/or imprisionment.

Contractor Signature                                  Printed Name                                 Date

IL452FL01                                                                                                              Page 1 of 1

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