Application For Employment Of Disabled Person - New Hampshire Department Of Labor

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STATE OF NEW HAMPSHIRE
DEPARTMENT OF LABOR
PO BOX 2076
CONCORD, NH 03302-2076
APPLICATION FOR EMPLOYMENT OF DISABLED PERSON
Under the provisions of RSA 279:22, A requirement for application for special authorization to
establish a sub-minimum wage rate for employees who are impaired by physical or mental disabilities
was created by the Legislature. A procedure for application and for approval by the Commissioner is
established by Rule Lab 804.
New Application
or
Renewal Application
(Circle one)
Employer:______________________________________________Telephone #__________________
Address:___________________________________________________________________________
No.
Street
City or Town
Employee:_____________________________________________Telephone #__________________
Address:___________________________________________________________________________
No.
Street
City or Town
Description of the mental or physical disability (attach medical record showing the disability)_______
__________________________________________________________________________________.
__________________________________________________________________________________.
Type of work_______________________________________________________________________
Requested sub-minimum rate per hour____________________
Date employment is to begin____________________19_____
Date authorization is to expire___________________19_____
__________________________________.
Signature of Applicant
__________________________________.
Position of Applicant
Tel. #
_______________
19______
_________________________________
Date Applicant submitted
Signature of Employee

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