## Employer

### Employer Information

Legal Name of Employer Does the Employer have a Trade Name? Trade Name Has the Employer’s legal name changed since its last application? Prior Legal Name of Employer Physical Address of Employer’s Main Establishment Does the Employer have a Parent Organization?
Parent Organization Legal Name Parent Organization Trade Name Parent Organization Address Send mail to Parent Organiation address?
Employer Status {{ appData.employer.employerStatusOther }} Is this employer a local or State educational agency?

### Number of Workers With Disabilities

When did the Employer’s most recently completed fiscal quarter end? What is the total number of workers with disabilities employed at subminimum wages during the most recently completed fiscal quarter at all establishments and work sites? Provide the number of workers with disabilities employed at subminimum wages for the most recently completed fiscal quarter in each of the following categories: Community Rehabilitation Program (Work Center) Hospital/Residential Care Facility (Patient Workers) School Work Experience Program (SWEP) Business Establishment

### Government Contracts

Does this employer manufacture items for the Federal Government under the Walsh-Healey Public Contracts Act (PCA)? Does this employer currently hold any contracts covered by the McNamara-O’Hara Service Contract Act (SCA)? What is the total number of current SCA-covered contracts under which workers with disabilities are employed and earning subminimum wages? SCA Wage Determination Attachment Since January 1, 2015, has this employer entered into a contract for services or concessions with the Federal Government that may be subject to Executive Order 13658 (Establishing a Minimum Wage for Contractors)?

### Additional Questions

Was the employer a representative payee Social Security Benefits during the most recently completed fiscal quarter? Total number of workers with disabilities for whom the facility was a representative payee during the most recently completed fiscal quarter? Did the employer take credit for the cost of providing facilities, such as board, lodging, and transportation, toward meeting the minimum wage or subminimum wage obligations during the most recently completed fiscal quarter?
Which type of deduction(s) did the employer take?

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Is this a request for Temporary Authority?