Form Wh-202 - Application For Authority To Employ Six Or Fewer Full-Time Students At Subminimum Wages In Retail Or Service Establishments Or Agriculture Under Regulations 29 C.f.r. Part 519

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Application for Authority to Employ Six or Fewer

U.S. Department of Labor

Full-Time Students at Subminimum Wages in

Wage and Hour Division

230 South Dearborn Street, Room 514

Retail or Service Establishments or Agriculture

Chicago, Illinois 60604-1757

Under Regulations 29 C.F.R. Part 519

OMB No.: 1235-0001

Note: Persons are not required to respond to this collection of information unless it displays a currently valid OMB

03-31-2014

control number.

Expires:

This is an application for retail or service establishments or agricultural employers to obtain authority to employ up to six full-time students at subminimum wage

rates on any workday under Section 14(b) of the Fair Labor Standards Act (FLSA). The subminimum rates paid full-time students under Section 14(b) may not

be less than 85 percent of the applicable minimum wage under Section 6 of the FLSA. The term “employer” as used by this application means the highest

structure of ownership or control and hence, may be more than one establishment or farm, i.e., the controlling conglomerate or enterprise would be the

“employer.” Thus, the limit of six full-time students applies to the “employer” and not to each establishment or farm in the enterprise or business. Those

seeking to employ more than six full-time students at subminimum wages throughout a single enterprise or business should complete and submit WH

Form 200 (Application for Authority to Employ Full-Time Students at Subminimum Wages in Retail or Service Establishments or Agriculture). Temporary authority

to employ full-time students at subminimum wages is effective when this form is properly completed and forwarded to the address listed above. This temporary

authority may be effective for a period of up to one year, provided that within 30 days of the forwarding, the Administrator of the Wage and Hour Division does not

deny the application, issue a certificate with modified terms or conditions, or expressly extend the 30-day period of review. See reverse for more information about

temporary authority. Please submit one copy of the completed form to the address shown above. Retain a completed copy for your records. A certificate may not be

granted unless a properly completed application has been received and approved.

1. This is (check one):

FOR USDOL USE ONLY

Initial Application

Pending

Denied

Issued

Withdrawn

Revoked

Issue/W Pend.

Renewal Application (complete following):

Postmark Date

Current Certicate Number:

Print Cert.

New Cert No.

Certificate Expiration Date:

Effective

Expiration

Remarks:

Total number of full-time students paid subminimum

wages during the most recent 12 months:

2. Name of Employer:

4. If full-time students will be employed at subminimum wages at

establishments other than that listed in block 2, provide the names

Street Address:

and addresses of those establishments:

City:

State:

Zip:

Telephone No.: (

)

Will you employ full-time students at the

above location at subminimum wages?

Yes

Mailing Address (if different than street address):

City:

State:

Zip:

Federal Employer

Identification Number (EIN):

3. Type of establishment(s) where full-time students will be employed at subminimum wages (check all that apply) and provide names

and addresses of each establishment in block 4:

Grocery Store

Full Service Restaurant

Convenience Store

Fast Food Restaurant

Clothing/Shoe Store

Hotel/Motel

Movie/Theater

General Merchandise

Hospital/Nursing

Other Retail/Service, Specify Type:

Agriculture, Specify Crop/Product

5. Representations, certification and signature:

I certify, as set forth in Regulations, 29 C.F.R. part 519, subpart B, that the employment of not more than six full-time students on any

workday will not reduce the full-time employment opportunities of other workers.

Authorized representative (print or type)

Signature of authorized representative:

Title (print or type)

Date application forwarded to USDOL:

Public Burden Statement

This collection of information is estimated to vary from 11 to 21 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, and maintaining your records. If you have any comments regarding this burden estimate or

any other aspect of this collection of information, including suggestions for reducing this burden, send them to the U.S. Department of Labor, Wage and Hour Division, Room S-3502,

200 Constitution Avenue, N.W., Washington, D.C., 20210 (do not send the completed application to this address).

Form WH-202

Rev. December 2010