Form Dlse 177 - Application For Sheltered Workshop License (Labor Code Section 1191.5)
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Return Application To:
State of California
DLSE Licensing
Department Of Industrial Relations
P.O. Box 420603
DIVISION OF LABOR STANDARDS ENFORCEMENT
San Francisco, CA 94142
APPLICATION FOR SHELTERED WORKSHOP LICENSE
Application is hereby made for a license to pay a special minimum wage to workers under provisions of Section 1191.5 of the Labor Code and Section 6
of the applicable Industrial Welfare Commission Order. PLEASE CAREFULLY READ THE ACCOMPANYING GENERAL INFORMATION AND
INSTRUCTIONS (DLSE 117-A) PRIOR TO COMPLETING THIS APPLICATION.
2. Certified by U.S. Department of Labor?
Yes
No
Name of Organization __________________________________________________ _________
1.
If Yes, Certificate No. ______________
Exp. Date :
(Provide a copy)
Street Address:
If No, on a separate page, provide an explanation
of reason for no certification
City: ___________________ County: ________________ State: ______ ZIP Code: _______
3. Certified by California Department of
Mailing Address (If Different than Street Address):
Rehabilitation?
Yes
No
If yes, Vendor No.
Exp. Date :
(Provide evidence)
City: ___________________ County: ________________ State: ______ ZIP Code: ______
3a: Certified by California Department of
Developmental Services/Regional Center?
Yes
No
If yes, Vendor No.
Person DLSE Should Contact:
Exp. Date :
(Provide evidence)
4. Federal Employer Identification No. (FEIN):
Telephone: (______) _____________
________
Type of Business__________________________________ IWC Order No.___________________
State Employer Identification No. (SEIN):
________
5. Applicable primary program:
6. Status (Check One):
Public (State or Local Government)
Private, For Profit
Private, Not For Profit
Other ______________
If you checked Public, STOP – you do not have to complete this application – See General Information and Instructions
7. This is an application for a:
New License
Renewal License
See General Information and Instructions (DLSE 117-A) for information required to be listed on separate sheet
If renewal, number of clients employed during period covered by previous license: _______________________
If renewal, wage rate paid during period covered by previous license:
If renewal, and wage rate is lower than previous license period, provide explanation and justification for lower wage rate. (Attach separate sheet if
necessary). You must also attach copies of documentation that evidences the justification for lower wage rate, including applicable work
measurement documentation.
8. Will clients work at locations other than the above address?
Yes
No
If yes, see General Information and Instructions (DLSE 117-A) for information required to be listed on separate sheet
9.
Has certification/accreditation to operate issued by any certifying/accrediting agency ever been denied, suspended or revoked?
Yes
No
If yes, explain circumstances (Attach a separate sheet if necessary)
10. Does applicant have current workers’ compensation insurance coverage?
Yes
No (Provide evidence of current coverage)
Name of Insurer: ________________________________________________ Policy Number _______________________
Address: ______________________________________________________
Expiration Date: ______________________
DLSE 117 (11/08)
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