Application for Special Industrial Homeworker Certificate

Application for Special Industrial
Homeworker’s Certificate
                                                                                 U.S. Department of Labor
                                                                                  Wage and Hour Division
                                                                                  230 South Dearborn Street, Room 530
                                                                                  Chicago, Illinois 60604

                                                                                                                                         OMB No.: 1235-0001
                                                                                                                                         Expires: 07-31-2027

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)


4. City or Town, State, ZIP Code                                                   5. Age                         6. Telephone Number (Include Area Code)
                                                                                                                     (         )
7. Explain fully why you are unable to work in a factory:




8. a. Do You Hold a State Homeworker Certificate?                b. If “Yes,” Name State                                 c. Expiration Date of State Certificate


I have read the statements in this application and ask that the requested certificate be granted.
Signature of Homeworker (If worker cannot write, signature may be made by mark (X) and witnessed by another person.)
Signature or Mark (X) of Homeworker Applicant:                 Date:                           Signature of Witness (If Necessary):




                                                             Public Burden Statement
According to the Paperwork Reduction Act of 1995, no persons are required to respond to this collection of information unless it displays a
currently valid OMB control number.

The Department of Labor estimates it will take an average of 30 minutes for respondents to complete this collection of information, including the
time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the
collection of information. If you have any comments regarding this burden estimate or any other aspect of this collection information, including
suggestions for reducing this burden, send them to the Administrator, Wage and Hour Division, U.S. Department of Labor, Room S-3502, 200
Constitution Avenue, NW, Washington, DC 20210. DO NOT SEND THE COMPLETED FORM TO THIS OFFICE.

                                                                    (continued on next page)                                                     Form WH-2
                                                                                                                                           Rev. December 2010
 Section II. Information to Be Furnished by Employer
 9. Name and Address, Including ZIP Code of Employer                           10. Name of State Vocational Rehabilitation Agency, if Any,
                                                                                   Supervising Homeworker’s Employment




11. If work is to be distributed to homeworker from other than above
    address, enter name and address of firm or individual distributing work.




I certify that the answers to the above questions are true and correct.
                                                                                  (        )
                                                                                                (Telephone Number Including Area Code)



     (Print or Type Name of Employer or Authorized Representative)                                               (Title)



          (Signature of Employer or Authorized Representative)                                                   (Date)



 Section III. Report of Medical Examination

12. Name of Person Examined


Nature of Disability




     Application to Work at Home Because of Inability to Work in a Factory Due to Physical Disability. How and to what extent does the disability
     affect the ability of the applicant to undertake work in a factory?
 A



     Application to Work at Home Due to Need to Care for an Invalid. Does the disability of the invalid warrant care to the extent of prohibiting
     employment of the applicant away from home?   Yes       No. If “Yes,” explain nature and extent of care required.

 B



13. What Is the Prognosis?




14. Print or Type Name and Address, Including ZIP Code,                        15. Signature of Examining Physician
    of Examining Physician

                                                                               16. Date


                                                                                                                                           Form WH-2
                                                                                                                                     Rev. December 2010