U.S. Department of Labor Application for Special Industrial Homeworker’s Certificate Employment Standards Administration Wage and Hour Division 230 South Dearborn Street, Room 514 Chicago, Illinois 60604 Note: Persons are not required to respond to this collection of information unless it displays a currently valid OMB control number. OMB No.:1215-0005 Expires: 01-31-2011 Instructions: Prepare three copies of this form and forward the original to the address shown above. The duplicate is to be kept by the employer and the other copy given to the homeworker applicant. All questions must be answered in full. The homeworker applicant is to furnish information for Section I. The employer furnishes information for Section II. The signature of each is required on the application. Section III, Report of Medical Examination, should be completed by a licensed physician. Public Use Statement: Fair Labor Standards Act (FLSA) section 11 (d), 29 U.S.C. § 211(d) authorizes this report. Completion of Form WH-2 is necessary to obtain certificates to employ individual homeworkers in one of the restricted homework industries noted in item I, below. Completion of the form is voluntary; however, failure to provide the information will result in non-issuance of a homeworker certificate and such employment in a restricted industry will be in violation of the FLSA. (See 29 C.F.R. part 530). This is an application form only and not a certificate. The Department of Labor uses the information provided to determine whether terms and conditions necessary to issue an individual certificate have been met. Section I. Information to Be Furnished by Homeworker 1. Certificate is requested for employment in the industry checked below: Button & Buckle Manufacturing Gloves and Mittens Jewelry Manufacturing Embroideries Handkerchief Manufacturing Knitted Outerwear 2. Print or type Name of Homeowner Applicant 3. Address (Street No., Apt. No., if Any) 4. City or Town, State, ZIP Code 5. Age Women's Apparel 6. Telephone Number (Include Area Code) ( ) 7. Explain fully why you are unable to work in a factory: 8. a. Do You Hold a State Homeworker Certificate? b. If “Yes,” Name State c. Expiration Date of State Certificate I have read the statements in this application and ask that the requested certificate be granted. Signature of Homeworker (If worker cannot write, signature may be made by mark (X) and witnessed by another person.) Signature or Mark (X) of Homeworker Applicant: Date: Signature of Witness (If Necessary): Public Burden Statement The Department of Labor estimates it will take an average of 30 minutes for respondents to complete this collection of information, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. If you have any comments regarding this burden estimate or any other aspect of this collection information, including suggestions for reducing this burden, send them to the Administrator, Wage and Hour Division, U.S. Department of Labor, Room S-3502, 200 Constitution Avenue, NW, Washington, DC 20210. DO NOT SEND THE COMPLETED FORM TO THIS OFFICE. (continued on next page) Form WH-2 Rev. January 2008 American LegalNet, Inc. www.FormsWorkflow.com Section II. Information to Be Furnished by Employer 9. Name and Address, Including ZIP Code of Employer 10. Name of State Vocational Rehabilitation Agency, if Any, Supervising Homeworker’s Employment 11. If work is to be distributed to homeworker from other than above address, enter name and address of firm or individual distributing work. I certify that the answers to the above questions are true and correct. ( ) (Telephone Number Including Area Code) (Print or Type Name of Employer or Authorized Representative) (Title) (Signature of Employer or Authorized Representative) (Date) Section III. Report of Medical Examination 12. Name of Person Examined Nature of Disability Application to Work at Home Because of Inability to Work in a Factory Due to Physical Disability. How and to what extent does the disability affect the ability of the applicant to undertake work in a factory? A Application to Work at Home Due to Need to Care for an Invalid. Does the disability of the invalid warrant care to the extent of prohibiting employment of the applicant away from home? Yes No. If “Yes,” explain nature and extent of care required. B 13. What Is the Prognosis? 14. Print or Type Name and Address, Including ZIP Code, of Examining Physician 15. Signature of Examining Physician 16. Date American LegalNet, Inc. www.FormsWorkflow.com Form WH-2 Rev. January 2008