Application for Authorization to Employ A Student-Learner at Subminimum Wages U.S. Department of Labor Employment Standards Administration Wage and Hour Division 230 South Dearborn Street, Room 514 Chicago, Illinois 60604 OMB No. 1215-0192 Expires: 3-31-2012 Instructions: Form WH-205 is completed by an employer to obtain certification to employ OFFICIAL USE ONLY student-learners at wages lower than the Federal minimum wage to prevent curtailment of opportunities for employment. Submission of this information is voluntary, but failure to A. Control number submit the information will prohibit the Wage and Hour Division from authorizing the B. Effective date employment of student-learners at subminimum rates. 29 U.S.C. § 214(a); 29 C.F.R. § 520.501. C. Expiration date The school officials' certification in Item 27 of the application provides temporary authority to D. Reviewing official employ the named student-learner under the terms proposed in the application which are in accordance with sections 520.502 and .503 of the Student-Learner Regulations (29 C.F.R. Part 520). The authority begins on the date the application is forwarded to the Regional Office of the Employment Standards Administration. At the end of 30 days, this authority is extended to become the approved certificate unless the Administrator or his/her authorized representative denies the application, issues a certificate with modified terms and conditions, or expressly extends the period of review. Note that the certificate is valid for no more than 1 school year and does not extend beyond the date of graduation. READ CAREFULLY THE INSTRUCTIONS FOR COMPLETING THIS FORM. PRINT OR TYPE ALL ANSWERS 1. Name and address, including zip code, of Establishment making application: 2. Type of business and products manufactured, sold, or services rendered: 3A. Name and address of student-learner: B. Date of birth: (Month, Day, Year) 4. Name and address, including zip code, of school in which studentlearner is enrolled. 5. Proposed beginning date of employment (Month, Day, Year) 6. Proposed ending date of employment (Month, Day, Year) 7. Proposed graduation date (Month, Day, Year) 17. Title of student-learner occupation: 8. Number of weeks in school year 18. Number of employees in this establishment 9. Total hours of school instruction per week 19. Number of experienced employees in student-learner's occupation 10. Number of school hours directly related to employment training 20. Minimum hourly wage rate of experienced workers in item 19 11. How is employment training scheduled (weekly, alternate weeks, etc.)? 21. Subminimum wage(s) to be paid student-learner (if a progressive wage schedule is proposed, enter each rate and specify the period during which it will be paid): 12. Number of weeks of employment training at subminimum wages 13. Number of hours of employment training a week 14. Are Federal Vocational Education Funds being used for this program? 15. Was this program authorized by the State Board of Vocational Education? 16. If the answer to item 15 is ''No'', give the name of the recognized educational body which approved this program: 22. Is an age or Employment Certificate on file in this establishment for this student-learner? (If not, see instructions). Yes No 23. Is it anticipated that the student-learner will be employed in the performance of a government contract subject to the Walsh-Healey Public Contracts Act or the Service Contract Act? Yes ATTACH SEPARATE PAGES IF NECESSARY No Form WH-205 Rev. July 2009 American LegalNet, Inc. www.FormsWorkFlow.com 24. Outline the school instruction directly related to the employment training (list courses, etc.) 25. Outline training on-the-job (describe briefly the work process in which the student-learner will be trained and list the types of any machines used). 26. Signature of student-learner I have read the statements made above and ask that the requested certificate, authorizing my employment training at subminimum wages and under the conditions stated, be granted by the Administrator or his/her authorized representative. Signature of student-learner Print or type name of student-learner 27. CERTIFICATION BY SCHOOL OFFICIAL I certify that the student named herein will be receiving instruction in an accredited school and will be employed pursuant to a bona fide vocational training program, and that the application is propperly executed in conformance with sections 520.502 and .503 of the Student- Learner Regulation. (Print or type name of official) Signature of School Official Title Date 28. CERTIFICATION BY EMPLOYER OR AUTHORIZED REPRESENTATIVE: I certify, in applying for this certificate, that all of the foregoing statements are, to the best of my knowledge and belief, true and correct. (Print or type name of employer or representative) Date Signature of employer or representative Date Title Tel. No. (Include Area Code) Tel. No. (Include Area Code) ATTACH SEPARATE SHEETS IF NECESSARY Public Burden Statement Persons are not required to respond to this collection of information unless it displays a currently valid OMB control number. This report is authorized by section 14(a) of the Fair Labor Standards Act (FLSA). 29 U.S.C. § 214(a). Your response is voluntary. The Department of Labor uses the information provided on this application in determining whether to authorize employment of student-learners at wages lower than the Federal minimum wage. Public reporting burden for this collection of information is estimated to average 30 minutes per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the U.S. Department of Labor, Administrator, Wage and Hour Division, Room S-3502, 200 Constitution Avenue, N.W., Washington, D.C. 20210. DO NOT SEND THE COMPLETED FORM TO THIS OFFICE. Form WH-205 Rev. July 2009 American LegalNet, Inc. www.FormsWorkFlow.com