Form SFN51371 "Application for Sub-minimum Wage for Individuals With Disabilities" - North Dakota

What Is Form SFN51371?

This is a legal form that was released by the North Dakota Department of Labor and Human Rights - a government authority operating within North Dakota. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on October 1, 2013;
  • The latest edition provided by the North Dakota Department of Labor and Human Rights;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form SFN51371 by clicking the link below or browse more documents and templates provided by the North Dakota Department of Labor and Human Rights.

ADVERTISEMENT
ADVERTISEMENT

Download Form SFN51371 "Application for Sub-minimum Wage for Individuals With Disabilities" - North Dakota

Download PDF

Fill PDF online

Rate (4.6 / 5) 46 votes
Page background image
Return completed application to:
APPLICATION FOR SUB-MINIMUM WAGE FOR
600 E Boulevard Ave Dept 406
INDIVIDUALS WITH DISABILITIES
Bismarck ND 58505-0340
NORTH DAKOTA DEPARTMENT OF LABOR AND HUMAN RIGHTS
701-328-2660
Fax 701-328-2031
ND Toll-Free 1-800-582-8032
SFN 51371 (Rev. 10-2013)
TTY: 1-800-366-6888
www.nd.gov/labor
Is this application for a(n)
Initial certificate?
Renewal certificate?
34-06-15 NDCC Special license to employ at less than minimum wage. The commissioner may issue to an employee whose productive capacity for
the work to be performed is impaired by physical or mental disability, or to any student or learner enrolled in a vocational eduction or related program, a
special license authorizing the employment of that licensee at less than the minimum wage. The commissioner may also issue special licenses to community
rehabilitation programs for the handicapped which engage in the occupation and responsibility of representing and placing for the purpose of training,
learning, or employment of those employees whose productive capacity for the work to be performed is impaired by physical or mental disability. The
commissioner shall issue such licenses under rules adopted by the commissioner.
TO BE COMPLETED BY EMPLOYEE
Telephone Number
Name of Employee
Date of Birth
Address of Employee
City
State
ZIP Code
I have read the statements in this application and ask that the requested certificates be granted.
X
Signature of Applicant
Date
TO BE COMPLETED BY EMPLOYER
Telephone Number
Name of Employer
Address of Employer
City
State
ZIP Code
Employer's Type of Business
How long has the worker been employed by the firm?
How long at present job?
Job description of the employee's position (describe in detail). Continue on separate sheet, if necessary.
Job Title
Amount other employees are paid for this position
Amount employer proposes employee be paid
$
Per
$
Per
Reason for arriving at this amount? (Be specific and describe exactly what affects the employee's productivity and to what percentage in relation to an
average worker.) Has a time study to determine the commensurate wage for the applicant been completed? Has a copy been enclosed? Continue on
separate sheet, if necessary.
I certify that, to the best of my knowledge and belief, all statements are true and accurate.
X
Signature of Employer or Authorized Official
Date
Return completed application to:
APPLICATION FOR SUB-MINIMUM WAGE FOR
600 E Boulevard Ave Dept 406
INDIVIDUALS WITH DISABILITIES
Bismarck ND 58505-0340
NORTH DAKOTA DEPARTMENT OF LABOR AND HUMAN RIGHTS
701-328-2660
Fax 701-328-2031
ND Toll-Free 1-800-582-8032
SFN 51371 (Rev. 10-2013)
TTY: 1-800-366-6888
www.nd.gov/labor
Is this application for a(n)
Initial certificate?
Renewal certificate?
34-06-15 NDCC Special license to employ at less than minimum wage. The commissioner may issue to an employee whose productive capacity for
the work to be performed is impaired by physical or mental disability, or to any student or learner enrolled in a vocational eduction or related program, a
special license authorizing the employment of that licensee at less than the minimum wage. The commissioner may also issue special licenses to community
rehabilitation programs for the handicapped which engage in the occupation and responsibility of representing and placing for the purpose of training,
learning, or employment of those employees whose productive capacity for the work to be performed is impaired by physical or mental disability. The
commissioner shall issue such licenses under rules adopted by the commissioner.
TO BE COMPLETED BY EMPLOYEE
Telephone Number
Name of Employee
Date of Birth
Address of Employee
City
State
ZIP Code
I have read the statements in this application and ask that the requested certificates be granted.
X
Signature of Applicant
Date
TO BE COMPLETED BY EMPLOYER
Telephone Number
Name of Employer
Address of Employer
City
State
ZIP Code
Employer's Type of Business
How long has the worker been employed by the firm?
How long at present job?
Job description of the employee's position (describe in detail). Continue on separate sheet, if necessary.
Job Title
Amount other employees are paid for this position
Amount employer proposes employee be paid
$
Per
$
Per
Reason for arriving at this amount? (Be specific and describe exactly what affects the employee's productivity and to what percentage in relation to an
average worker.) Has a time study to determine the commensurate wage for the applicant been completed? Has a copy been enclosed? Continue on
separate sheet, if necessary.
I certify that, to the best of my knowledge and belief, all statements are true and accurate.
X
Signature of Employer or Authorized Official
Date
SFN 51371 (Rev. 10-2013)
TO BE COMPLETED BY PHYSICIAN
This report is requested in connection with an application for a certificate authorizing the employment of the individual named in this application at a
subminimum wage under North Dakota Century Code 34-06-15. A certificate will be granted only if the disability is handicapping for the work performed.
Only a licensed physician may complete this section. The North Dakota Department of Labor and Human Rights does not pay for this examination.
If other sufficient evidence exists it can be sent in place of Physician's authorization. Example: Information in a student's IEP or IHP.
Nature of Applicant's Disability:
Mentally Retarded/Developmentally Disabled (MR/DD)
Blindness
Physical Disability
Mental Illness (ME)
Age
Loss of Limb
Other (specify)
What is the prognosis?
How and to what extent does the disability affect the applicant's ability to perform the type of work listed on the previous page?
Physician's Name
Address of Clinic
Name of Clinic
City
State
ZIP Code
Telephone Number
Date
I verify that the above named patient has a disability that affects the individual's earning or productive capacity.
X
Signature of Physician
Page of 2