Form Llc-4 "Application for Special Certificate for the Employment of Learners" - Pennsylvania

Form LLC-4 or the "Application For Special Certificate For The Employment Of Learners" is a form issued by the Pennsylvania Department of Labor & Industry.

Download a PDF version of the Form LLC-4 down below or find it on the Pennsylvania Department of Labor & Industry Forms website.

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B
L
L
C
ureau of
aBor
aw
ompLianCe
1301 L
& i
B
aBor
ndustry
uiLding
s
& f
s
eventh
orster
treets
h
, pa 17121
arrisBurg
1-800-932-0665
www.dli.state.pa.us
application for special certificate
for the employment of learners
A separate application must be filed for each establishment for which a certificate is sought. This form should be signed by
the employer and two (2) copies returned to the Bureau of Labor Law Compliance, 1301 Labor & Industry Building, Seventh
& Forster Streets, Harrisburg, PA 17121. This is an application form only.
I apply to the Department of Labor & Industry for a SPECIAL CERTIFICATE authorizing the employment of learners under
the provisions of Section 4(b) of the Pennsylvania Minimum Wage Act, at less than the stated minimum, but not less than
85% of the applicable minimum wage rate.
Name of Establishment_______________________________________________________________________________
Address___________________________________________________________________________________________
STREET
CITY
COUNTY
STATE
ZIP CODE
Type of Business_________________________________________________
Total No. of Employees ______________
This establishment’s annual gross business is (state approximate amount) $_ __________________
This establishment is
G
is____
G
is not part of a business with more than one branch.
The combined annual gross business of all the branches is (state approximate amount) $_________________________ _
Type of Occupation(s) under Special Certificate _ _________________________________________________________
No. of regular employees in the occupation(s) involved _ _ ___________________________________________________
Proposed duration of learning period __________________ weeks. Proposed Hourly Wage: $ _ _ ____________________
Nature and extent of instruction and supervision: (Please submit detailed report on separate sheet.)
I have read the Regulations, under Pennsylvania’s Minimum Wage Act, and agree to comply with the conditions specified
for the duration of the permit.
I certify that the employment of learners at a special minimum wage rate will not create a substantial probability of reducing
the employment opportunities for other workers.
I further understand that furnishing of false statements in this application is a crime and is subject to criminal penalties under
Section 4904 of the Pennsylvania Crimes Code (relating to unsworn falsification to authorities).
_Date ___________________________________
Signed _ _ ________________________________________________
Title _ __________________________________________________
Telephone _______________________________________________
Auxiliary aids and services are available upon request to individuals with disabilities.
Equal Opportunity Employer/Program
LLC-4 12-06
B
L
L
C
ureau of
aBor
aw
ompLianCe
1301 L
& i
B
aBor
ndustry
uiLding
s
& f
s
eventh
orster
treets
h
, pa 17121
arrisBurg
1-800-932-0665
www.dli.state.pa.us
application for special certificate
for the employment of learners
A separate application must be filed for each establishment for which a certificate is sought. This form should be signed by
the employer and two (2) copies returned to the Bureau of Labor Law Compliance, 1301 Labor & Industry Building, Seventh
& Forster Streets, Harrisburg, PA 17121. This is an application form only.
I apply to the Department of Labor & Industry for a SPECIAL CERTIFICATE authorizing the employment of learners under
the provisions of Section 4(b) of the Pennsylvania Minimum Wage Act, at less than the stated minimum, but not less than
85% of the applicable minimum wage rate.
Name of Establishment_______________________________________________________________________________
Address___________________________________________________________________________________________
STREET
CITY
COUNTY
STATE
ZIP CODE
Type of Business_________________________________________________
Total No. of Employees ______________
This establishment’s annual gross business is (state approximate amount) $_ __________________
This establishment is
G
is____
G
is not part of a business with more than one branch.
The combined annual gross business of all the branches is (state approximate amount) $_________________________ _
Type of Occupation(s) under Special Certificate _ _________________________________________________________
No. of regular employees in the occupation(s) involved _ _ ___________________________________________________
Proposed duration of learning period __________________ weeks. Proposed Hourly Wage: $ _ _ ____________________
Nature and extent of instruction and supervision: (Please submit detailed report on separate sheet.)
I have read the Regulations, under Pennsylvania’s Minimum Wage Act, and agree to comply with the conditions specified
for the duration of the permit.
I certify that the employment of learners at a special minimum wage rate will not create a substantial probability of reducing
the employment opportunities for other workers.
I further understand that furnishing of false statements in this application is a crime and is subject to criminal penalties under
Section 4904 of the Pennsylvania Crimes Code (relating to unsworn falsification to authorities).
_Date ___________________________________
Signed _ _ ________________________________________________
Title _ __________________________________________________
Telephone _______________________________________________
Auxiliary aids and services are available upon request to individuals with disabilities.
Equal Opportunity Employer/Program
LLC-4 12-06
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