"Approval Form for Sub-minimum Wage or No Wage Rate for Work-Based Activities Under Rsa 279:22-aa" - New Hampshire

Approval Form for Sub-minimum Wage or No Wage Rate for Work-Based Activities Under Rsa 279:22-aa is a legal document that was released by the New Hampshire Department of Labor - a government authority operating within New Hampshire.

Form Details:

  • Released on October 30, 2018;
  • The latest edition currently provided by the New Hampshire Department of Labor;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;

Download a fillable version of the form by clicking the link below or browse more documents and templates provided by the New Hampshire Department of Labor.

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Download "Approval Form for Sub-minimum Wage or No Wage Rate for Work-Based Activities Under Rsa 279:22-aa" - New Hampshire

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STATE OF NEW HAMPSHIRE
DEPARTMENT OF LABOR
PO BOX 2076
CONCORD, NH 03302-2076
PHONE (603) 271-3176
FAX (603) 271-2668
E-Mail:
InspectionDiv@dol.nh,gov
Approval Form for Sub-Minimum Wage or
No Wage Rate for Work-Based Activities under RSA 279:22-aa
Please type or print all information
School/institution/Organization__________________________________________
Secondary
Post-secondary
Other
Address____________________________________________________________________________________________________
Street
Town/City
State
Zip Code
If disabled learner check one:
VR
AA
CMHC
Provider Agency
No Wage Rate
Sub-Minimum Wage Rate Requested,
amount $_______________
Program Name:_____________________________________________________________________________________________
Contact Person___________________________ Title___________________ Tel._________________ FAX. _________________
E-Mail_________________________________________________________
Type of Placement (check only one):
Job Shadow
Clinical
Work Experience
Internship
Service Learning
Mentor Program
Situational Assessment
Training Program
Other ____
Career Interest & Objective (or attach a course description or syllabus):
Is academic credit given for this program?
Yes
No
Hours per day _______
Days per week_______
Total number of days at business site_______
Supervision: Please describe how the student/learner(s) will be supervised and by whom_____________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
1. Does each place of business have a safety program?
Yes
No Explain_________________________________________
2. Is there any hazardous equipment involved?
Yes
No Type_________________________________________________
3. Has all Safety Training been completed (as applicable to each site)? Including specific training for equipment as noted above.
Yes
No
Explain________________________________________________________________________________
The information above as provided is accurate and we guarantee that this placement in no way establishes an employee/employer
relationship between the student(s) and the business site at which they are placed.
Attach Pre-Screening Forms for each business participating in this placement. Notify the DOL of any additions to this list, via additional
Pre-Screening Forms. Also attach a sample copy of Agreement or Contract for this placement.
Print Name____________________________________________ Authorized Signature________________________________________________
Title__________________________________________________
For DOL use only
Approved
Rejected
DOL Authorized Signature___________________________________________________ Date________________
Reason for Rejection:
Please provide a more detailed Career Interest & Objective, or attach a course description or syllabus
Other
WH_NRWWBA_rev181030
STATE OF NEW HAMPSHIRE
DEPARTMENT OF LABOR
PO BOX 2076
CONCORD, NH 03302-2076
PHONE (603) 271-3176
FAX (603) 271-2668
E-Mail:
InspectionDiv@dol.nh,gov
Approval Form for Sub-Minimum Wage or
No Wage Rate for Work-Based Activities under RSA 279:22-aa
Please type or print all information
School/institution/Organization__________________________________________
Secondary
Post-secondary
Other
Address____________________________________________________________________________________________________
Street
Town/City
State
Zip Code
If disabled learner check one:
VR
AA
CMHC
Provider Agency
No Wage Rate
Sub-Minimum Wage Rate Requested,
amount $_______________
Program Name:_____________________________________________________________________________________________
Contact Person___________________________ Title___________________ Tel._________________ FAX. _________________
E-Mail_________________________________________________________
Type of Placement (check only one):
Job Shadow
Clinical
Work Experience
Internship
Service Learning
Mentor Program
Situational Assessment
Training Program
Other ____
Career Interest & Objective (or attach a course description or syllabus):
Is academic credit given for this program?
Yes
No
Hours per day _______
Days per week_______
Total number of days at business site_______
Supervision: Please describe how the student/learner(s) will be supervised and by whom_____________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
1. Does each place of business have a safety program?
Yes
No Explain_________________________________________
2. Is there any hazardous equipment involved?
Yes
No Type_________________________________________________
3. Has all Safety Training been completed (as applicable to each site)? Including specific training for equipment as noted above.
Yes
No
Explain________________________________________________________________________________
The information above as provided is accurate and we guarantee that this placement in no way establishes an employee/employer
relationship between the student(s) and the business site at which they are placed.
Attach Pre-Screening Forms for each business participating in this placement. Notify the DOL of any additions to this list, via additional
Pre-Screening Forms. Also attach a sample copy of Agreement or Contract for this placement.
Print Name____________________________________________ Authorized Signature________________________________________________
Title__________________________________________________
For DOL use only
Approved
Rejected
DOL Authorized Signature___________________________________________________ Date________________
Reason for Rejection:
Please provide a more detailed Career Interest & Objective, or attach a course description or syllabus
Other
WH_NRWWBA_rev181030