Fillable Printable Form WH-205
Fillable Printable Form WH-205
Form WH-205
Application for Authorization to
U.S. Department of Labor
Employ A Student-Learner at
Wage and Hour Division
Subminimum Wages
OMB No. 1235-0001
Expires: 12-31-2019
Instructions: Form WH-205 is completed by an employer to obtain certification to employ
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
submit the information
will prohibit the Wage and Hour Division from authorizing the
employment of student-learners
at subminimum rates. 29 U.S.C. § 214(a); 29 C.F.R. § 520.501.
OFFICIAL USE ONLY
A. Control number
B. Effective date
C. Expiration date
D. Reviewing official
The school officials' certification in Item 27 of the application provides temporary authority to
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). T
he authority begins on the date the application is forwarded to the Regional Office of
the E
mployment 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
3A. Name and address of student-learner:
1. Name and address, including zip code, of Establishment making
application:
B. Date of birth: (Month, Day, Year)
2. Type of business and products manufactured, sold, or services
rendered:
4. Name and address, including zip code, of school in which student-
l
earner is enrolled.
7. Proposed graduation date (Month, Day, Year)
17. Title of student-learner occupation:
10. Number of school hours directly related to
employment training
20. Minimum hourly wage rate of experienced
workers in item 19
21. Subminimum wage(s) to be paid student-learner
11. How is employment training scheduled
(weekly, alternate weeks, etc.)?
specify the period during which it will be paid):
22. Is an age or Employment Certificate on file in this establishment for
this student-learner? (If not, see instructions).
Yes
No
15. Was this program authorized by the State Board of
Vocational Education?
23. Is it anticipated that the student-learner will be employed in the
16. If the answer to item 15 is ''No'', give the name of the recognized
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
5. Proposed beginning date of employment
(Month, Day, Year)
6. Proposed ending date of employment
(Month, Day, Year)
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?
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
(if a progressive wage schedule is proposed, enter each rate and
ATTACH SEPARATE PAGES IF NECESSARY
Form WH-205
Rev. December 2010
230 South Dearborn Street, Room 514
Chicago, Illinois 60604
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
REPRESENTATIVE:
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 prop-
perly executed in conformance with sections 520.502 and .503 of the
Student- Learner Regulation.
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 official)
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.
Signature of School Official
Date
(Print or type name of employer or representative)
Signature of employer or representative
Date
Form WH-205
Rev. December 2010
