Form WH-200 Application for Authority to Employ Full-Time Students a

Application for Authority to Employ
Full-Time Students at Subminimum Wages in
Retail or Service Establishments or Agriculture
Under Regulations 29 C.F.R. Part 519

U.S. Department of Labor
Employment Standards Administration
Wage and Hour Division
230 South Dearborn Street, Room 514
Chicago, Illinois 60604-1757

Note: Persons are not required to respond to this collection of information unless it displays a currently valid OMB
control number.

OMB No.: 1215-0032
Expires: 11-30-2008

This is an application for retail or service establishments or agricultural employers to obtain authority to employ more than six full-time students at subminimum
wage rates under Section 14(b) of the Fair Labor Standards Act (FLSA). The subminimum rates paid full-time students under Section 14(b) may not be less
than 85 percent of the applicable minimum wage under Section 6 of the FLSA. Employers requesting authority to employ six or fewer full-time students at
subminimum wage rates throughout a single enterprise must submit Form WH-202 rather than this form. Please submit one copy of the completed form
to the address shown above. Retain a completed copy for your records. A certificate may not be granted unless a properly completed application has been
received and approved.

1. This is (check one):

4. Establishment covered by this application where full-time
students will be employed at subminimum wages if different
than block 3:

Initial Application
Renewal Application (complete following):

Name of Establishment:

Current Certicate Number:

Street Address:

Certificate Expiration Date:

/

/
City:

2. Authority Requested (check one):

Greater than ten percent of the total monthly hours
(you must complete Block #6 below if this is an
initial application)

5. Type of establishment (check one):

3. Name of Employer:
Street Address:
Mailing Address (if
different than street address):

State:

Zip:

Check here if mail is to be sent to above
address rather than to address listed in block 3:

Ten percent of the total monthly hours

City:

State:

Zip:

Grocery Store

Full Service Restaurant

Convenience Store

Fast Food Restaurant

Clothing/Shoe Store

Hotel/Motel

Movie/Theater

General Merchandise

Hospital/Nursing Home

Federal Employer

Identification Number (EIN):

Other Retail/Service, Specify Type:
Agriculture, Specify Crop/Product:

A separate application is required for each establishment
or farm for which authority is requested to employ fulltime students at subminimum wages.

6. This item need only be completed on initial request for more than ten percent – See 29 C.F.R. §519.6(f)-(h)
A.
Calendar
Month

January
February
March
April
May
June
July
August
September
October
November
December

B.
Year

C.
D.
Total
Hours of fullhours
time students
of all
that were paid
employees
subminimum
wages

E.
F.
Full-time
Percentage
student hours
allowance
as percent of
requested
total hours
(D ÷ C) X 100%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
see reverse

G.
Check one:
Check here if you used
data from your own
establishment.
Check here if you used
base year data from
another establishment
and provide the name
and address of the
establishment below:

Form WH-200
Rev. June 2008

7. If this is a renewal application, please provide the following
information for the establishment named in block #4:

FOR USDOL USE ONLY

A. The total number of hours worked by

all employees (including managers)

during the most recent 12 months:

Pending

Denied

Issued

Withdrawn

Revoked

Issue/W Pend.

RO

B. The total number of hours worked by

full-time students during the most recent

12 months that were paid at subminimum

wage rates:

DO

Print Cert.
Effective

C. The total number of full-time students

who were paid subminimum wages

during the most recent 12 months

(if you had no full-time students paid
less than the minimum wage, enter “0”)

New Cert No.
/

Base year:

/
60/61

Expiration
66/67

73/74

/

/
Archive

Remarks:

8. Person USDOL should contact regarding this application:
Name:
Telephone No.: (

)

9. REPRESENTATIONS AND WRITTEN ASSURANCES:
Your signature on this application certifies that you have read the application and that to the best of your knowledge and belief the answers and information
given in the application are true; that the representations set forth in support of this application to obtain full-time student authorization are true; that you are
duly authorized to sign this application; and that the authorization, if issued, is subject to withdrawal or annulment in accordance with 29 C.F.R. part 528.
I represent that as set forth in regulations governing the employment of full-time students (29 C.F.R. part 519) the following conditions exist in this establishment:
(a)

The issuance of the authority requested herein is necessary to prevent a curtailment of opportunities for employment.

(b)

The employment of full-time students will not create a substantial probability of reducing the full-time employment opportunities of persons other than
those employed under the regulations.

(c)

Full-time students are available for employment at subminimum wages.

(d)

Abnormal labor conditions, such as a strike or lockout, do not exist at this establishment.

(e)

There are no serious outstanding violations of the provisions of previous full-time student authority issued to this establishment nor have there been any
serious violations of other provisions of the FLSA.

(f)

Full-time students are employed in compliance with applicable local ordinances, State laws, and other Federal laws.

(g)

The issuance of this authority will not result in a reduction of a wage rate paid to a current employee, including student employees.

10. SIGNATURE OF AUTHORIZED REPRESENTATIVE:
Name (Print or Type)

Title

Signature

Date

This application form must be completed to receive a certificate authorizing the employment of more than six full-time students at subminimum
wage rates (which may not be less than 85% of the applicable minimum wage) in retail or service establishments and in agriculture. Please
consult 29 C.F.R. part 519 for detailed information concerning the employment of full-time students at subminimum wage rates. Please submit the
completed application to the Wage and Hour Division at the address listed on the front of this form.
Public Burden Statement
We estimate that it will take an average of 11 to 31 minutes per response to complete this collection of information, including time for reviewing instructions,
searching existing data sources, gathering and maintaining the data needed, completing and reviewing the collection information, and maintaining
your records. If you have any comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for
reducing this burden, send them to the U.S. Department of Labor, Administrator, Wage and Hour Division, Room S-3502, 200 Constitution Avenue, N.W.,
Washington, D.C., 20210 (please do not send the completed application to this address).

2

Form WH-200
Rev. June 2008