WH-205 Application for Authorization to Employ A Student-Learne

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

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