DLSE 106 (/19) 1 of 2 State of California Department Of Industrial Relations DIVISION OF LABOR STANDARDS ENFORCEMENT Return Application To: DLSE Licensing 1515 Clay Street, Suite Oakland, CA 94612 APPLICATION FOR SPECIAL MINIMUM WAGE LICENSE (Labor Code section 1191) Application is hereby jointly made for a license to pay a special minimum wage to an individual under the provisions of Secti on 1191 of the Labor Code and Section 6 of the applicable Industrial Welfare Commission Order . PLEASE CAREFULLY READ THE ACCOMPANYING GENERAL INFORMATION AND INSTRUCTIONS (DLSE 117 - A) PRIOR TO COMPLETING THIS APPLICATION. Establishment employing worker with a disability: 1. Name Street Address: City: County: State: ZIP Code: Mailing Address (If Different than Street Address): City: County: State: ZIP Code: Contact Person/Telephone: Type of Business IWC Order No. Federal Employer ID No. (FEIN): State Employer ID No. (SEIN): 1a . Certified by U.S. Department of Labor? Yes No If Yes, Certificate No. Exp. Date : (Provide a copy) If No, on a separate page, provide an explanation of reason for no certification Worker with a Disability: 2 . Name Street Address: City: State: ZIP Code: If legally conserved, Parent/Legal Guardian: 3. Name: Street Address: City: State: ZIP Code: Telephone: ( ) Referring Organization: 4. Name Street Address: City: County: State: ZIP Code: Mailing Address (If Different than Street Address): City: County: State: ZIP Code: Contact Person/Telephone: Status : Public Private, For Profit Private, Not For Profit Other 4a. Certified by U.S. Department of Labor? Yes No If Yes, Certificate No. Exp. Date : (Provide a copy) If No, on a separate page, provide an explanation of reason for no certification) 5.Applicable primary program: 6. Status of Establishment Listed in No. 1, above: (Check One): Public (State or Local Government) Private, For Profit Private, Not For Profit Other If you checked Public, STOP you do not have to complete this application See General Information and Instructions 7.This is an application for New License Renewal License See General Information and Instructions (DLSE 117 - A) for information required to be listed on separate sheet Proposed wage rate: $ per (hour/day/week/month ) for hours per day/ days per week Plus (specify meals, lodging, other items) If renewal, wage rate paid during period covered by previous license: If renewal, and wage rate is lower than previous license period, provide explanation and justification for lower wage rate. (Attach separate sheet if necessary). You must also attach copies of documentation that evidences the justification for lower wage rate, including work measurement documentation. P ri n t F orm American LegalNet, Inc. www.FormsWorkFlow.com DLSE 106 (/19) 2 of 2 8. Will individual work at locations other than the above address? Yes No If yes, see General Information and Instructions (DLSE 117 - A) for information required to be listed on separate sheet 9. Has certification/accreditation to operate issued to the establishment and/or referring organization listed in No. 1 and/or 3 ever been denied, suspended or revoked by any certifying/accrediting agency? Yes No If yes, explain circumstances (Attach a separate sheet if necessary) coverage? Yes No (Provide evidence of current coverage) Name of Insurer: Policy Number Address: Expiration Date: 11. Nature capacity: Mental Illness Visual Impairment Hearing Impairment Age Related Alcoholism Drug Addictions Neuromuscular General No Primary Group Developmental Disability Specify: Other Specify: 12. Describe work measurement method and evaluation process, including detailed description of work to be performed. (Attach a se parate sheet if necessary) You must also attach copies of work measurement documentation evidencing justification for wage rate being requested (See General Information and Instructions (DLSE 117 - A) for instructions regarding required information/documentation) 13. Date of last wage review 14. Date of last prevailing wage survey CERTIFICATION I certify that I have read this form and to the best of my knowledge and belief, all answers and information given in the application and attachments and the representations set forth in support of this application to obtain or continue authorization to pay workers with disabilities at special minimum wage rates are true. I further represent that I have been notified of my rights and request that the license to be paid at a special minimum wage rate be issued. name signature Date name signature Date CERTIFICATION I certify that I have read this form and to the best of my knowledge and belief, all answers and information given in the application and attachments and the representations set forth in support of this application to obtain or continue authorization to pay workers with disabilities at special minimum wage rates are true. I further represent that the following terms and conditions exist (or will exist for initial applicants): (a) workers employed (or who will be employed) under the authority of Labor Code 2471191 have disabilities for the work to be performed; (b) wage rates paid (or which will be paid) to workers with disabilities under the authority of Labor Code 2471191 are commensurate with those paid experienced workers, who do not have disabilities, in industry in the vicinity for essentially the same type, quality and quantity of work; (c) the operations are (or will be) in compliance with the applicable Industrial Welfare Commission Order, the California Labor Code and all applicable State and Federal Law; (d) records will be maintained as required by Section 7 of the Industrial Welfare Commission Orders and consistent with the requirements of 29 CFR 525 including documentation of disability, productivity, work measurements and prevailing wage surveys; (e) a copy of the license shall be maintained at each location where individuals are employed; (f) a copy of the DOL poster Rights for Workers with Disabilities Paid At Special Minimum shall be posted at each location where individuals will be employed (g) consistent with the requirements of DOL, a wage review must be completed at least once every six months and a prevailing wage survey must be performed annually; (h) consistent with the requirements of Cal/OSHA an Injury and Illness Prevention Program (IIPP) shall be maintained along with all required Cal/OSHA documentation and reports; and (i) written and oral advice of wage rate being paid has been provided to each worker and/or his/her guardian. Print Name Title Date Signature American LegalNet, Inc. www.FormsWorkFlow.com