PDF document

- 1 -

Application for Authorization to U.S. Department of Labor
Employ A Student-Learner at Wage and Hour Division

Subminimum Wages 230 South Dearborn Street, Room 530
Chicago, Illinois 60604
OMB No. 1235-0001
Expires: 09-30-2021
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 represen-
tative denies the application, issues a certificate with modified terms and conditions, or ex-
pressly 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 3A. Name and address of student-learner:
application:

2. Type of business and products manufactured, sold, or services B. Date of birth: (Month, Day, Year)
rendered:
4. Name and address, including zip code, of school in which student-
learner 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 20. Minimum hourly wage rate of experienced
employment training workers in item 19
11. How is employment training scheduled 21. Subminimum wage(s) to be paid student-learner
(weekly, alternate weeks, etc.)? (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 22. Is an age or Employment Certificate on file in this establishment for
this student-learner? (If not, see instructions).
14. Are Federal Vocational Education Funds being used
for this program?
Yes No
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 23. Is it anticipated that the student-learner will be employed in the
educational body which approved this program: performance of a government contract subject to the Walsh-Healey
Public Contracts Act or the Service Contract Act?
Yes No

Form WH-205
ATTACH SEPARATE PAGES IF NECESSARY Rev. December 2010

- 2 -

Enlarge image

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.

Print or type name of student-learner Signature of student-learner Date

27. CERTIFICATION BY SCHOOL OFFICIAL 28. CERTIFICATION BY EMPLOYER OR AUTHORIZED
I certify that the student named herein will be receiving instruction REPRESENTATIVE:
in an accredited school and will be employed pursuant to a bona
fide vocational training program, and that the application is prop- I certify, in applying for this certificate, that all of the foregoing
perly executed in conformance with sections 520.502 and .503 of the statements are, to the best of my knowledge and belief, true and
Student- Learner Regulation. correct.

(Print or type name of official) (Print or type name of employer or representative)

Signature of School Official Date Signature of employer or representative Date
Title Title

Tel. No. Tel. No.
(Include Area Code) (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. December 2010

PDF file checksum: 3582898849

(Plugin #1/9.12/13.0)