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Application For Special Minimum Wage License (Labor Code Section 1191) DLSE 106 - California
| Application For Special Minimum Wage License (Labor Code Section 1191) Form. This is a California form and can be used in DLSE Forms Workers Comp . |
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Return Application To: DLSE Licensing P.O. Box 420603 San Francisco, CA 94142 State of California Department Of Industrial Relations DIVISION OF LABOR STANDARDS ENFORCEMENT APPLICATION FOR SPECIAL MINIMUM WAGE LICENSE (Labor Code section 1191) Application is hereby jointly made for a license to pay a special minimum wage to an individual under the provisions of Section 1191 of the Labor Code and Section 6 of the applicable Industrial Welfare Commission Order. PLEASE CAREFULLY READ THE ACCOMPANYING GENERAL INFORMATION AND INSTRUCTIONS (DLSE 117-A) PRIOR TO COMPLETING THIS APPLICATION. Establishment employing worker with a disability: 1. Name __________________________________________________________________________ Street Address: City: ___________________ County: ________________ State: ______ ZIP Code: _______ Mailing Address (If Different than Street Address): 1a. Certified by U.S. Department of Labor? No Yes If Yes, Certificate No. ______________ Exp. Date : (Provide a copy) If No, on a separate page, provide an explanation of reason for no certification 1b. Certified by California Department of Rehabilitation? Yes No If yes, Vendor No. (Provide evidence) Exp. Date : Certified by California Dept of Developmental Yes No Services/Regional Center? If yes, Vendor No. Exp. Date : (Provide evidence) City: ___________________ County: ________________ State: ______ ZIP Code: ______ Contact Person/Telephone: Type of Business__________________________________ IWC Order No.___________________ Federal Employer ID No. (FEIN): ________State Employer ID No. (SEIN): ________ Worker with a Disability: 2. Name ____________________________________________________ If legally conserved, Parent/Legal Guardian: 3. Name: _____________________________________________________ Street Address: _______________________________________________ City: ___________________ State: ___________ ZIP Code: _______ Telephone: (______) _____________ Street Address: ______________________________________________ City: _________________ State: _____________ ZIP Code: _______ Referring Organization: 4. Name _________________________________________________________________________ Street Address: City: ___________________ County: ________________ State: ______ ZIP Code: _______ Mailing Address (If Different than Street Address): 4a. Certified by U.S. Department of Labor? Yes No If Yes, Certificate No. ______________ (Provide a copy) Exp. Date : If No, on a separate page, provide an explanation of reason for no certification) 4b. Certified by California Department of Yes No Rehabilitation? If yes, Vendor No. (Provide evidence) Exp. Date : Certified by California Dept of Developmental Yes No Services/Regional Center? If yes, Vendor No. Exp. Date : (Provide evidence City: ___________________ County: ________________ State: ______ ZIP Code: ______ Contact Person/Telephone: Status: Public Private, For Profit Private, Not For Profit Other _______ 5. Applicable primary program: 6. Status of Establishment Listed in No. 1, above: (Check One): Public (State or Local Government) Private, For Profit Private, Not For Profit Other ______________ If you checked Public, STOP you do not have to complete this application See General Information and Instructions 7. This is an application for a: New License Renewal License See General Information and Instructions (DLSE 117-A) for information required to be listed on separate sheet Proposed wage rate: $___________ per _________________ (hour/day/week/month ) for ______________hours per day/ ___________ days per week Plus ____________________________________________________ (specify meals, lodging, other items) If renewal, wage rate paid during period covered by previous license: If renewal, and wage rate is lower than previous license period, provide explanation and justification for lower wage rate. (Attach separate sheet if necessary). You must also attach copies of documentation that evidences the justification for lower wage rate, including work measurement documentation. DLSE 106 (11/08) 1 of 2 American LegalNet, Inc. www.FormsWorkflow.com 8. 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, suspended or revoked by any certifying/accrediting agency? Yes No If yes, explain circumstances (Attach a separate sheet if necessary) 10. Does establishment listed in No. 1 above have current workers' compensation insurance coverage? (Provide evidence of current coverage) Name of Insurer: ________________________________________________ Address: ______________________________________________________ 11. Nature of disability which impairs applicant's earning capacity: Mental Illness Alcoholism Visual Impairment Drug Addictions Hearing Impairment Neuromuscular Age Related General No Primary Group Policy Number _______________________ Expiration Date: ______________________ Yes No 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 _
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