Form Wh-205 - Application For Authorization To Employ A Student-Learner At Subminimum Wages Page 2
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224. 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.
Signature of student-learner
Date
Print or type name of student-learner
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
I certify, in applying for this certificate, that all of the foregoing
fide vocational training program, and that the application is prop-
statements are, to the best of my knowledge and belief, true and
perly executed in conformance with sections 520.502 and .503 of the
correct.
Student- Learner Regulation.
(Print or type name of official)
(Print or type name of employer or representative)
Signature of School Official
Date
Signature of employer or representative
Date
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.
Form WH-205
Rev. December 2010
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