or 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
U.S. Department of Labor
Wage and Hour Division
230 South Dearborn Street, Room 530
Chicago, Illinois 60604-1757
Note: Persons are not required to respond to this collection of information unless it displays a currently valid OMB
control number.
OMB No.: 1235-0001
Expires: 09-30-2021
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.
This is (check one):
Initial Application
Renewal Application (complete following):
Current Certicate Number:
Certificate Expiration Date: / /
Total number of full-time students paid subminimum
wages during the most recent 12 months:
2.
Name of Employer:
Street Address:
City: State: Zip:
Telephone No.: ( )
Will you employ full-time students at the
above location at subminimum wages? Yes No
Mailing Address (if different than street address):
City: State: Zip:
Federal Employer
Identification Number (EIN):
Denied Issued
/ /
/ / / /
FOR USDOL USE ONLY
Pending
Withdrawn Revoked Issue/W Pend.
Postmark Date RO
Print Cert. New Cert No.
Effective Expiration
4. If full-time students will be employed at subminimum wages at
establishments other than that listed in block 2, provide the names
and addresses of those establishments:
1.
2.
3.
4.
5.
Clothing/Shoe Store Hotel/Motel
Hospital/Nursing
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
Movie/Theater General Merchandise
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.
6.
Authorized representative (print or type) 7. Signature of authorized representative:
8. Title (print or type) 9. Date application forwarded to USDOL:
lic 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
