U.S. Department of Labor
Wage and Hour Division
Attn: Homeworker Certification
230 S. Dearborn Street
Chicago, IL 60604-1757
Telephone: (312) 596-7195
APPLICATION FOR CERTIFICATE TO EMPLOY HOMEWORKERS
OMB No. 1235-0001
(name of employer)
(address of establishment,
including mailing address)
hereby make application to employ homeworkers in the
(state & Zip code)
industry for the manufacture of
(e.g., jewelry, gloves & mittens, etc.)
Attached is a list of the names, addresses, and
(item(s) to be produced by homeworkers)
languages spoken (if other than English) of homeworkers that I intend to employ under this certificate.
I hereby assure that:
All homeworkers will be paid in accordance with the minimum wage and overtime provisions of the
Fair Labor Standards Act (FLSA). 29 C.F.R. § 530.103(a).
No minor under 16 will be employed to perform homework. 29 C.F.R. § 530.103(b).
Records will be maintained in accordance with section 11(c) of the FLSA and Regulations. 29 U.S.C.
§ 211(c); 29 C.F.R. § 530.103(c).
All homeworkers will complete a Homeworker Handbook in accordance with Regulations, 29 C.F.R.
§ 516.31 and will be instructed to accurately record all hours worked, piece work information and
business related expenses in the handbook. 29 C.F.R. § 530.103(d)-(e).
All records will be made available for inspection and transcription by the Administrator or a duly
authorized and designated representative, or transcription by the employer upon written request.
29 C.F.R. § 530.103(f).
Piece rates paid to homeworkers will be calculated using stop watch time studies or other work
measurement methods. 29 C.F.R. § 530.103(g).
All homeworkers will be encouraged to cooperate with the Department of Labor in any investigation
that may be made by the Administrator or a duly authorized and designated representative.
29 C.F.R. § 530.103(h).
Where homeworkers will be employed in jewelry manufacturing, their work will be limited
exclusively to the stringing of beads and other jewelry and the carding and packaging of jewelry.*
29 C.F.R. § 530.103(i).
I understand that violations of the FLSA, of FLSA regulations, or of these assurances, may result in the
assessment of civil money penalties or revocation of my certificate. 29 C.F.R. § 530.301-.304.
Rev. December 2010
Notification of address change of the employer must be provided in writing within 30 days to the
Administrator, Wage and Hour Division, 200 Constitution Avenue, N.W., Washington, D.C. 20210.
29 C.F.R. § 530.102. Approval of this application does not relieve an employer from compliance with
standards applicable to homeworkers under State law or local ordinance.
* As set forth in Regulations, 29 C.F.R. § 530.101, the terms, ''carding and packaging of jewelry" include
the attaching of jewelry to cards, boxing and wrapping, and the use of common household glues
available to the general public, but do not include potentially hazardous operations such as the use of
industrial glues, epoxies, soldering irons, or heating elements.
Public Burden Statement
According to the Paperwork Reduction Act of 1995, no persons are required to respond to this collection of information unless it displays a
currently valid OMB control number. This information collection is authorized by section 11(d) of the FLSA and is required to obtain or
retain the benefit of a certificate permitting employment of homeworkers in industries restricted by Regulations 29 C.F.R. Part 530.
29 U.S.C. § 211(d); 29 C.F.R. §§ 530.2, .101-.102. We estimate that it will take an average of 30 minutes to complete this collection of
information, 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
nformation, 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.
SEND THE COMPLETED SURVEY TO THE ADDRESS ON THE FRONT OF THE FORM
Name of Homeworker
Address (street, city, state)
(if other than English)