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Get DoL WH-226 2016-2024

5. Primary Disability Group Employed Check One Mental Retardation MR Alcoholism AL General No Primary Group GI Mental Illness MI Drug Addictions DA Age Related AR Visual Impairment VI Neuromuscular NM Other OT Specify Hearing Impairment HI Developmental Disability DD Specify continued on next page Form WH-226 Rev. December 2010 8. U*S* Department of Labor Application for Authority to Employ Workers with Disabilities at Special Minimum Wages Wage and Hour Division 230 South Dearborn Street Room 514 Chicago Illinois 60604 OMB No* 1235-0001 Expires 03-31-2014 This is an application for the authority to employ workers with disabilities at special minimum wage rates under the Fair Labor Standards Act FLSA Walsh Healey Public Contracts Act PCA or McNamara O Hara Service Contract Act SCA. An instruction sheet for completing this form is contained on page 4. Please submit one copy of the completed form and any attachments to the address shown above. Retain a completed copy for your records. A certificate may not be granted by the Department of Labor unless a properly completed application has been received and approved* 29 U*S*C. 201 et seq. For USDOL Use Only 1. a* This is a request for authority to employ workers with disabilities for Check All Boxes that Apply Certificate Number Community Rehabilitation Center Work Center Effective Date Hospital/Residential Care Facility Patient Workers Business Establishment Special Workers Expiration Date / RO School Work Experience Program SWEP DO Remarks Employees b. This is Check One Paying SMW s Initial Application Complete All Items Print Certificate No Number of sites to receive a certificate Renewal Application Please Make Any Necessary Corrections to Reprinted Information Yes WS 6. List the name and address es of all branch establishments BR supported employment sites including enclaves SE or school work experience program sites SWEP to be covered by this certificate. Note A separate Supplemental Data Sheet WH-226A must be completed for every establishment where you employ workers with disabilities at special minimum wages including your main establishment and each establishment listed below. See page 4 of this application for definitions of BR SE and SWEP. Attach additional sheets if necessary. Current Certificate Number 2. Name of Employer Street Address Mailing Address If Different than Street Address City State Indicate if BR SE or SWEP County Name Address of Site Zip Code Federal Employer Identification Number EIN Person USDOL should contact Telephone 3. Parent Organization if different from that listed in 2 Name Address 7. Do you manufacture items for the Federal Government under PCA Check here if mail is to be sent to parent organization rather than 2. Do you perform any services for the Federal Government under SCA 4. Status Check One Public State or Local Government Private For Profit Private Not For Profit Other 3 Remember to attach copies of all current SCA Wage Determinations for those contracts upon which workers with disabilities are employed and earning special minimum wages. .

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