Fillable Printable Form WH-200
Fillable Printable Form WH-200
Form WH-200
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
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.: 1235-0001
Expires:12-31-2019
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):
Initial Application
Renewal Application (complete following):
Current Certicate Number:
Certificate Expiration Date: / /
2. Authority Requested (check one):
Ten percent of the total monthly hours
Greater than ten percent of the total monthly hours
(you must complete Block #6 below if this is an
initial application)
3. Name of Employer:
Street Address:
Mailing Address (if different than street address):
City: State: Zip:
Federal Employer
Identification Number (EIN):
A separate application is required for each establishment
or farm for which authority is requested to employ full-
time students at subminimum wages.
4. Establishment covered by this application where full-time
students will be employed at subminimum wages if different
than block 3:
Name of Establishment:
Street Address:
City: State: Zip:
Chec
k here if mail is to be sent to above
address rather than to address listed in block 3:
5. Type of establishment (check one):
Grocery Store Full Service Restaurant
Convenience Store Fast Food Restaurant
Clothing/Shoe Store Hotel/Motel
Movie/Theater General Merchandise
Hospital/Nursing Home
Other Retail/Service, Specify Type:
Agriculture, Specify Crop/Product:
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. B. C. D. E. F. G.
Calendar
Month
Year Total
hours
Hours of full-
time students
Full-time
student hours
Percentage
allowance
Check one:
of all
employees
that were paid
subminimum
wages
as percent of
total hours
(D
÷ C) X 100%
requested
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:
January % %
February % %
March % %
April % %
May % %
June % %
July % %
August % %
September % %
October % %
November % %
December % %
Form WH-200
Rev. December 2010
see reverse
7. If this is a renewal application, please provide the following
information for the establishment named in block #4:
A. The total number of hours worked by
all employees (including managers)
during the most recent 12 months:
B. The total number of hours work
ed by
full-time students during the most recent
12 months that were paid at subminimum
wage rates:
C. The total number of full-time students
who were paid subminimum w
ages
during the most recent 12 months
(if you had no full-time students paid
less than the minimum wage, enter “0”)
8. Person USDOL should contact regarding this application:
Name:
Denied Issued
DO
/ / / /
60/61 66/67 73/74
FOR USDOL USE ONLY
Pending
Withdrawn Revoked Issue/W Pend.
RO
Print Cert. New Cert No.
Effective Expiration
Base year: Archive
Remarks:
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. December 2010
