Any person desiring to be registered as a farm labor contractor shall apply for such registration on a form to be prescribed and furnished by the Department, which shall contain the following information:

1. (1) Name.
2. (2) Social Security Number or Federal Identification Number.
3. (3) Home address.
4. (4) Whether or not the applicant has registered pursuant to 7 U.S.C.A. § § 2041—2053.
5. (5) Whether or not the applicant possesses a valid driver’s license and the state and date of issue.
6. (6) Whether or not the applicant has ever been convicted of a crime or summary offense other than a nonmoving traffic violation.

7. (7) Whether or not the applicant will provide:

   1. (A) Transportation.
   2. (B) Food.
   3. (C) Lodging.
8. (8) The type and estimated numbers of workers to be provided.
9. (9) The names of the employers of the workers.
10. (10) The period of time during which workers shall be provided.
11. (11) The source of workers by state, territory or country.
12. (12) The names of any agents to be used.
13. (13) A complete set of applicant’s fingerprints.
14. (14) Two frontal pictures of the applicant no larger than two inches square.