Disclosure Statement Department of Labor and Industries Employment Standards Program Farm Labor Contractor PO Box 44510 Olympia WA 98504-4510 and Worker Farm Labor Contractor Information Farm Labor Contractor Business Name Contact Name Email Address Telephone Number Cell Phone Number Physical Address City State Zip + 4 Mailing Address (if different) City State Zip + 4 Surety Bond Name of Surety Amount of Bond – Surety Mailing Address City State Zip + 4 Washington Farm Labor Contractor’s Law requires all farm labor contractors to maintain a surety bond or cash deposit with the Department of Labor and Industries to ensure the payment of wages to workers. If you believe you are owed wages, you may make a claim against the bond or deposit. Contact your local office of the Department of Labor and Industries. See page 3 for a list of offices. Wages and Benefits Rate of Pay - For this job, you will be paid at the following rate (rate per hour or piece work) Bonus Bonuses will be given under the following conditions: Yes No Personal Loans Personal Loans will be given under the following conditions: Yes No Transportation Transportation will be provided under the following conditions/Costs: Yes No Housing/Boarding Housing/Boarding will be provided under the following conditions/costs: Yes No Health Care Health Care will be provided under the following conditions/costs: Yes No Day Care Services Day Care Services will be provided under the following conditions/costs: Yes No $ Any of the above costs will be no more than: Employment Conditions Work will begin on (approximate dates): And end on / / / / Days and Hours as follows: Sunday Hrs Tuesday Hrs Thursday Hrs Saturday Hrs Monday Hrs Wednesday Hrs Friday Hrs General Working Conditions activities and crops: – Other information, if any:
Department of Labor and Industries Employment Standards Program PO Box 44510 Olympia WA 98504-4510 Disclosure Statement Farm Labor Contractor and Worker Farm Labor Contractor Information Farm Labor Contractor Business Name Contact Name Email Address Telephone Number Cell Phone Number Physical Address City State Zip + 4 Mailing Address (if different) City State Zip + 4 Surety Bond – Name of Surety Amount of Bond Surety Mailing Address City State Zip + 4 Washington Farm Labor Contractor’s Law requires all farm labor contractors to maintain a surety bond or cash deposit with the Department of Labor and Industries to ensure the payment of wages to workers. If you believe you are owed wages, you may make a claim against the bond or deposit. Contact your local office of the Department of Labor and Industries. See page 3 for a list of offices. Wages and Benefits Rate of Pay - For this job, you will be paid at the following rate (rate per hour or piece work) Bonus Bonuses will be given under the following conditions: Yes No Personal Loans Personal Loans will be given under the following conditions: Yes No Transportation Transportation will be provided under the following conditions/Costs: Yes No Housing/Boarding Housing/Boarding will be provided under the following conditions/costs: Yes No Health Care Health Care will be provided under the following conditions/costs: Yes No Day Care Services Day Care Services will be provided under the following conditions/costs: Yes No Any of the above costs will be no more than: $ Employment Conditions Work will begin on (approximate dates): / / And end on / / Days and Hours as follows: Sunday Hrs Tuesday Hrs Thursday Hrs Saturday Hrs Monday Hrs Wednesday Hrs Friday Hrs General Working Conditions – activities and crops: Other information, if any:
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