F700-046-000 FLC Disclosure Statement (ENGLISH)

Wages and Benefits

Date(Required)

EE#(Required)

Employee Name(Required)

First Last

Rate of Pay(Required)

For this job, you will be paid at the following rate (rate per hour or piece work)

Bonus

Yes

No

Personal Loans

Yes

No

Transportation

Yes

No

Housing/Boarding

Yes

No

Day Care Services

Yes

No

Health Care

Yes

No

Health Care will be provided under the following conditions/costs:

Plan 1 - Emp. only $0.00/Emp+Child(ren) $13.54/week. Plan 2 - Emp. only 9.61% of income / Emp+Spouse 9.61%+100%/Emp+Child(ren) 9.61%+100% / Family 9.61%+100%

Employment Conditions

Work BEGINS on:(Required)

Work ENDS on:(Required)

Days and Hours as follows:(Required)

Sunday - 8 Hrs

Monday - 8 Hrs

Tuesday - 8 Hrs

Wednesday - 8 Hrs

Thursday - 8 Hrs

Friday - 8 Hrs

Saturday - 8 Hrs

General Working Conditions - activities and crops:

Agricultural Employer Information

Business Name (with whom the FLC contracts)

Contact Name

(owner or owner's agent)

Phone Number:

Mailing Address (if different):

Mailing Address City State ZIP Code

Working Conditions - Activities and Crops:

Labor Disputes

There is no Labor dispute at this work site

There is a labor dispute at this work site

Add another FLC Client?

Yes

No

Business Name #2 (with whom the FLC contracts)

Contact Name #2

(owner or owner's agent)

Phone Number #2:

Mailing Address #2 (if different):

Mailing Address City State ZIP Code

Working Conditions #2 - Activities and Crops:

Labor Disputes

There is no Labor dispute at this work site

There is a labor dispute at this work site

Commission Question

Does any arrangement exist with any owner or agent of any establishment at the place of employment under which the farm labor contractor will receive a fee or any other benefit resulting from any sales by such establishment to the workers?

No

Yes

Signatures

Employee Signature(Required)

NOTE: A copy of this form must be provided to the worker in English and in the language common to the worker.

Email

This field is for validation purposes and should be left unchanged.