Form Dlse 106 - Application For Special Minimum Wage License (Labor Code Section 1191) Page 2
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28. Will individual work at locations other than the above address?
Yes
No
If yes, see General Information and Instructions (DLSE 117-A) for information required to be listed on separate sheet
9. Has certification/accreditation to operate issued to the establishment and/or referring organization listed in No. 1 and/or 3 ever been denied,
Yes
No
suspended or revoked by any certifying/accrediting agency?
If yes, explain circumstances (Attach a separate sheet if necessary)
10. Does establishment listed in No. 1 above have current workers’ compensation insurance coverage?
Yes
No
(Provide evidence of current coverage)
Name of Insurer: ________________________________________________ Policy Number _______________________
Address: ______________________________________________________
Expiration Date: ______________________
11. Nature of disability which impairs applicant’s earning capacity:
Mental Illness
Visual Impairment
Hearing Impairment
Age Related
Alcoholism
Drug Addictions
Neuromuscular
General – No Primary Group
Developmental Disability Specify: ____________
Other Specify: __________________
12. Describe work measurement method and evaluation process, including detailed description of work to be performed. (Attach a separate sheet if
necessary) You must also attach copies of work measurement documentation evidencing justification for wage rate being requested (See General
Information and Instructions (DLSE 117-A) for instructions regarding required information/documentation)
13. Date of last wage review
14. Date of last prevailing wage survey
CERTIFICATION
I certify that I have read this form and to the best of my knowledge and belief, all answers and information given in the application and attachments
and the representations set forth in support of this application to obtain or continue authorization to pay workers with disabilities at special minimum
wage rates are true. I further represent that I have been notified of my rights and request that the license to be paid at a special minimum wage rate be
issued.
_______________________________________
___________________________________________
_________________________
Individual’s printed name
Individual’s signature
Date
_______________________________________
___________________________________________
________________________
If applicable, Parent/Guardian’s printed name
If applicable, Parent/Guardian’s signature
Date
CERTIFICATION
I certify that I have read this form and to the best of my knowledge and belief, all answers and information given in the application and attachments
and the representations set forth in support of this application to obtain or continue authorization to pay workers with disabilities at special minimum
wage rates are true. I further represent that the following terms and conditions exist (or will exist for initial applicants):
(a) workers employed (or who will be employed) under the authority of Labor Code §1191 have disabilities for the work to be performed;
(b) wage rates paid (or which will be paid) to workers with disabilities under the authority of Labor Code §1191 are commensurate with
those paid experienced workers, who do not have disabilities, in industry in the vicinity for essentially the same type, quality and quantity of
work;
(c) the operations are (or will be) in compliance with the applicable Industrial Welfare Commission Order, the California Labor Code and all
applicable State and Federal Law;
(d) records will be maintained as required by Section 7 of the Industrial Welfare Commission Orders and consistent with the requirements of
29 CFR 525 including documentation of disability, productivity, work measurements and prevailing wage surveys;
(e) a copy of the license shall be maintained at each location where individuals are employed;
(f) a copy of the DOL poster “Employee Rights for Workers with Disabilities Paid At Special Minimum Wages” shall be posted at each
location where individuals will be employed
(g) consistent with the requirements of DOL, a wage review must be completed at least once every six months and a prevailing wage survey
must be performed annually;
(h) consistent with the requirements of Cal/OSHA an Injury and Illness Prevention Program (IIPP) shall be maintained along with all
required Cal/OSHA documentation and reports; and
(i) written and oral advice of wage rate being paid has been provided to each worker and/or his/her guardian.
_________________________________________________________
Print Name
Title
Date
__________________________________________________________
Signature
DLSE 106 (11/08)
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