Form Wh-226 - Application For Authority To Employ Workers With Disabilities At Special Minimum Wages - 2008
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4U.S. Department of Labor
Application for Authority to Employ
Workers with Disabilities at Special
Employment Standards Administration
Wage and Hour Division
Minimum Wages
230 South Dearborn Street, Room 514
Chicago, Illinois 60604
Note: Persons are not required to respond to this collection of information unless it displays a currently valid OMB
OMB No.: 1215-0005
Expires:
01-31-2011
control number.
This is an application for the authority to employ workers with disabilities at special minimum wage rates under the Fair Labor Standards Act (FLSA),
Walsh–Healey Public Contracts Act (PCA), or McNamara–O’Hara Service Contract Act (SCA). An instruction sheet for completing this form is contained on page
4. Please submit one copy of the completed form, and any attachments, to the address shown above. Retain a completed copy for your records. A certificate
may not be granted by the Department of Labor unless a properly completed application has been received and approved. 29 U.S.C. § 201, et seq.
For USDOL Use Only
1. a. This Is a Request for Authority to Employ Workers with
Disabilities for (Check All Boxes that Apply):
Certificate Number:
Community Rehabilitation Center (Work Center)
Effective Date:
/
/
Expiration Date:
/
/
Hospital/Residential Care Facility (Patient Workers)
RO:
DO:
Business Establishment (Special Workers)
Remarks:
School Work Experience Program (SWEP)
Employees:
Paying SMW’s:
Yes
No
b. This Is (Check One):
Initial Application (Complete All Items)
Number of Sites to Receive a Certificate:
Renewal Application (Please Make Any Necessary
Print Certificate:
Yes
No
WS:
Corrections to Reprinted Information)
6. List the name and address(es) of all branch establishments (BR), supported
Current Certificate Number:
employment sites, including enclaves (SE), or school work experience
program sites (SWEP) to be covered by this certificate. Note: A separate
2. Name of Employer:
Supplemental Data Sheet (WH-226A) must be completed for every estab-
lishment where you employ workers with disabilities at special minimum
Street Address:
wages (including your main establishment and each establishment listed
below). See page 4 of this application for definitions of BR, SE and SWEP.
Mailing Address (If Different
Attach additional sheets if necessary.
than Street Address):
Indicate if BR,
SE or SWEP
Name & Address of Site
City:
County:
State:
ZIP Code:
Federal Employer Identification
Number (EIN):
Person USDOL Should Contact:
Telephone: (
)
3. Parent Organization if Different from that Listed in #2:
Name:
Address:
7. Do you manufacture items for the Federal Government under PCA?
Check Here if Mail Is to Be Sent to Parent Organization Rather than #2.
Yes
No
Do you perform any services for the Federal Government under SCA?
4. Status (Check One):
Yes
No
Public (State or Local Government)
Private, For Profit
3 Remember to attach copies of all current SCA Wage Determinations for
those contracts upon which workers with disabilities are employed and
Private, Not For Profit
Other
earning special minimum wages.
5. Primary Disability Group Employed (Check One):
Mental Retardation (MR)
Alcoholism (AL)
General — No Primary Group (GI)
Mental Illness (MI)
Drug Addictions (DA)
Age Related (AR)
Visual Impairment (VI)
Neuromuscular (NM)
Other (OT) Specify:
Hearing Impairment (HI)
Developmental Disability (DD) Specify:
(continued on next page)
Form WH-226
Rev. January 2008
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