Form Wh-2 - Application For Special Industrial U.s. Department Of Labor Homeworker'S Certificate

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Application for Special Industrial

U.S. Department of Labor

Homeworker’s Certificate

Wage and Hour Division

230 South Dearborn Street, Room 514

Chicago, Illinois 60604

OMB No.: 1235-0001

Expires: 03-31-2014

Instructions: Prepare three copies of this form and forward the original to the address shown above. The duplicate is to be kept by the employer and the

other copy given to the homeworker applicant. All questions must be answered in full. The homeworker applicant is to furnish information for Section I. The

employer furnishes information for Section II. The signature of each is required on the application. Section III, Report of Medical Examination, should be

completed by a licensed physician.

Public Use Statement: Fair Labor Standards Act (FLSA) section 11 (d), 29 U.S.C. § 211(d) authorizes this report. Completion of Form WH-2 is necessary

to obtain certificates to employ individual homeworkers in one of the restricted homework industries noted in item I, below. Completion of the form is volun-

tary; however, failure to provide the information will result in non-issuance of a homeworker certificate and such employment in a restricted industry will be in

violation of the FLSA. (See 29 C.F.R. part 530). This is an application form only and not a certificate. The Department of Labor uses the information provided

to determine whether terms and conditions necessary to issue an individual certificate have been met.

Section I. Information to Be Furnished by Homeworker

1. Certificate is requested for employment in the industry checked below:

Button & Buckle Manufacturing

Gloves and Mittens

Jewelry Manufacturing

Women's Apparel

Embroideries

Handkerchief Manufacturing

Knitted Outerwear

2. Print or type Name of Homeworker Applicant

3. Address (Street No., Apt. No., if Any)