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I
U.S. Department of Labor
Wage and Hour Division
Attn: Homeworker Certification
230 S. Dearborn Street
Room 530
Chicago, IL 60604-1757
Telephone: (312) 596-7195
APPLICATION FOR CERTIFICATE TO EMPLOY HOMEWORKERS
OMB No. 1235-0001
Expires:09-30-2021
,
,
(name of employer)
at
(address of establishment,
(county)
including mailing address)
,
hereby make application to employ homeworkers in the
(state & Zip code)
industry for the manufacture of
(e.g., jewelry, gloves & mittens, etc.)
.
Attached is a list of the names, addresses, and
(item(s) to be produced by homeworkers)
languages spoken (if other than English) of homeworkers that I intend to employ under this certificate.
I hereby assure that:
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All homeworkers will be paid in accordance with the minimum wage and overtime provisions of the
Fair Labor Standards Act (FLSA). 29 C.F.R. § 530.103(a).
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No minor under 16 will be employed to perform homework. 29 C.F.R. § 530.103(b).
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Records will be maintained in accordance with section 11(c) of the FLSA and Regulations. 29 U.S.C.
§ 211(c); 29 C.F.R. § 530.103(c).
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All homeworkers will complete a Homeworker Handbook in accordance with Regulations, 29 C.F.R.
§ 516.31 and will be instructed to accurately record all hours worked, piece work information and
business related expenses in the handbook. 29 C.F.R. § 530.103(d)-(e).
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All records will be made available for inspection and transcription by the Administrator or a duly
authorized and designated representative, or transcription by the employer upon written request.
29 C.F.R. § 530.103(f).
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Piece rates paid to homeworkers will be calculated using stop watch time studies or other work
measurement methods. 29 C.F.R. § 530.103(g).
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All homeworkers will be encouraged to cooperate with the Department of Labor in any investigation
that may be made by the Administrator or a duly authorized and designated representative.
29 C.F.R. § 530.103(h).
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Where homeworkers will be employed in jewelry manufacturing, their work will be limited
exclusively to the stringing of beads and other jewelry and the carding and packaging of jewelry.*
29 C.F.R. § 530.103(i).
I understand that violations of the FLSA, of FLSA regulations, or of these assurances, may result in the
assessment of civil money penalties or revocation of my certificate. 29 C.F.R. § 530.301-.304.
Date
Signature
Title
Firm
Form WH-46
Rev. December 2010
