Form Wh 2 PDF Details

The WH-2 form, officially termed as the Application for Special Industrial U.S. Department of Labor Homeworker's Certificate, represents a critical pathway for homeworkers seeking legitimate employment within certain restricted industries. Managed by the Wage and Hour Division and issued at a specific address in Chicago, Illinois, this form requires detailed information from both the homeworker applicants and their potential employers to ensure compliance with the Fair Labor Standards Act (FLSA). With sections designated for personal details, employer information, and a mandatory report of medical examination to be completed by a licensed physician, the form intricately guides applicants through the processes necessary for certification. The availability of such a certification enables individuals unable to work in conventional settings, due to various reasons including physical disabilities or the need to care for a dependent, to engage in productive employment from the comfort of their homes. Additionally, the form highlights the importance of providing complete and accurate information, as failure to do so could not only prevent the issuance of a certificate but also potentially result in legal violations under the FLSA. It's noteworthy that completion of the WH-2 form is voluntary, yet crucial for employment in specific sectors such as jewelry manufacturing, glove making, and several others, thus supporting diverse workforce participation while adhering to legal standards.

QuestionAnswer
Form NameForm Wh 2
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesIllinois, 2010, WH-2, FLSA

Form Preview Example

Application for Special Industrial

U.S. Department of Labor

Homeworker’s Certiicate

Wage and Hour Division

 

 

230 South Dearborn Street, Room 514

 

Chicago, Illinois 60604

OMB No.: 1235-0001

Expires: 03-31-2014

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 certiicates 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 certiicate 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 certiicate. The Department of Labor uses the information provided to determine whether terms and conditions necessary to issue an individual certiicate have been met.

Section I. Information to Be Furnished by Homeworker

1. Certiicate is requested for employment in the industry checked below:

Button & Buckle Manufacturing

Embroideries

Gloves and Mittens

Handkerchief Manufacturing

Jewelry Manufacturing

Knitted Outerwear

Women's Apparel

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 Certiicate?

b. If “Yes,” Name State

c. Expiration Date of State Certiicate

I have read the statements in this application and ask that the requested certiicate 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

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

10.Name of State Vocational Rehabilitation Agency, if Any, Supervising Homeworker’s Employment

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, of Examining Physician

15. Signature of Examining Physician

16. Date

Form WH-2

Rev. December 2010

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1. It is important to fill out the wh 2 form accurately, so pay close attention when working with the parts containing all of these blanks:

WH-2 conclusion process described (portion 1)

2. The subsequent step is usually to complete these fields: a Do You Hold a State Homeworker, b If Yes Name State, c Expiration Date of State, I have read the statements in this, Signature of Homeworker If worker, Signature or Mark X of Homeworker, Date, Signature of Witness If Necessary, Public Burden Statement, According to the Paperwork, continued on next page, Form WH, and Rev December.

Tips on how to prepare WH-2 portion 2

3. In this specific step, check out Name and Address Including ZIP, Name of State Vocational, Supervising Homeworkers Employment, If work is to be distributed to, address enter name and address of, I certify that the answers to the, Telephone Number Including Area, Print or Type Name of Employer or, Signature of Employer or, Title, Date, Section III Report of Medical, Name of Person Examined, and Nature of Disability. All of these will need to be filled out with highest accuracy.

Signature of Employer or, If work is to be distributed to, and Nature of Disability of WH-2

4. It is time to start working on this fourth portion! In this case you'll have all these Application to Work at Home, Application to Work at Home Due to, No If Yes explain nature and, Yes, What Is the Prognosis, Print or Type Name and Address, Signature of Examining Physician, of Examining Physician, Date, Form WH, and Rev December fields to do.

The way to complete WH-2 step 4

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