2017 Employer Certification Application
The application must be completed by the employer's designated person with the authority to represent the business or organization.

All applications will be reviewed by the Orange County Living Wage Certification Committee, which is empowered to make all final decisions on certification.

Application data is considered confidential and privileged information. It will only be shown to our Certification Committee members. No copies will be made or distributed.

Employers must reapply for Living Wage certification every two years.

Basic Business Information
1. What is the name of your business or organization? *
Your answer
2. Who should Orange County Living Wage use as the primary contact for your business or organization? This person will receive our internal communications to our Living Wage Certified Employers. *
Your answer
3. What is the street number and name of the MAILING address of your business or organization? *
Ex. 125 Maple St.
Your answer
4. If you have a Suite or Apt # in your MAILING address please list that here.
Ex. Suite 120
Your answer
5. City *
Your answer
6. State *
Your answer
7. Zip *
Your answer
8. What is the street number and name of the PHYSICAL address of your business or organization? *
If the PHYSICAL address is the same as the MAILING address write “SAME” and skip to q.13
Your answer
9. If you have a Suite or Apt # in your PHYSICAL address please list that here.
Ex. Suite 120
Your answer
10. City
Your answer
11. State
Your answer
12. Zip
Your answer
13. What is the best e-mail address for Orange County Living Wage to reach you, personally? *
Your answer
14. What e-mail address would you like listed in our online directory? *
Your answer
15. What best describes your organization? Select one. *
Required
16. Please describe your business or organization in 30 characters or fewer. For example, "shoe store" or "canoe manufacturing facility."
Your answer
17. Please provide a description of your business or organization for our website.
(Max 250 words)
Your answer
18. What is the main phone number for your business or organization?
nnn-nnn-nnnn
Your answer
19. What is the best phone number for Orange County Living Wage to contact you directly?
nnn-nnn-nnnn
Your answer
20. What is the URL for your business or organization’s website?
Your answer
EMPLOYEES AND WAGES
21. How many regular full and part-time employees do you have?
Note: Although the following individuals are included in q. 21, they need not be paid a living wage if they meet certain conditions: interns, apprentices, temporary or project-based employees working less than 90 days a year, minors working part-time, new hires in a probationary period not to exceed 90 days. For details, refer to our definitions: http://orangecountylivingwage.org/definitions/
Your answer
22. What number of the employees listed above are interns?
Your answer
23. What number of the employees listed above are apprentices?
Your answer
24. What number of the employees listed above are temporary or project-based employees working fewer than 90 days a year?
Your answer
25. What number of the employees listed above are minors working part time?
Your answer
26. What number of the employees listed above are new hires in a probationary period not to exceed 90 days?
Your answer
27. Of the remaining employees, are all current regular full- and part-time employees paid at least $13.15/hour?
Note: For tipped, commissioned, and variable-pay employees, total compensation must equal at least $13.15/hour (or at least $11.65/hour with health insurance).
28. How many tipped employees do you have?
Your answer
29. How many commissioned employees do you have?
Your answer
30. How many variable pay structure employees do you have?
Your answer
31. If you have tipped, commissioned, and variable pay employees, do you agree to allow an Orange County Living Wage team member to schedule interviews to confirm rates with a portion of your staff? These interviews will be scheduled through you when it is convenient for you.
32. Do you offer health insurance to your employees?
33. Do you pay at least 50% of the employees’ premiums?
34. Do you pay at least $11.65 per hour to all employees for which you provide health insurance?
35. Do you pay at least $13.15 per hour to all employees for which you do not provide health insurance?
Raises and Benefits Increase
36. Did you raise wages or benefits to qualify for the Orange County Living Wage Certification Program?
If you selected "No", proceed to the next section: Employer Attestation and Agreements
37. If you raised wages, what was the amt/ hour of increase (ex. $2.45)
Answer only if you selected "Yes" on question 36.
Your answer
38. If you raised wages, how many employees received an increase?
Answer only if you selected "Yes" on question 36.
Your answer
39. If you raised wages, what is the total annual cost of the increase?
Answer only if you selected "Yes" on question 36.
Your answer
40. If you increased benefits, how many employees received an increase?
Answer only if you selected "Yes" on question 36.
Your answer
41. If you increased benefits, what is the total annual cost of the increase?
Answer only if you selected "Yes" on question 36.
Your answer
Employer Attestation and Agreements
42. Do you attest that the information provided in this application is true and accurate and that you are not withholding any information that would affect this application? *
43. Do you agree to notify Orange County Living Wage if employee compensation falls below the Orange County Living Wage requirements? *
44. Do you agree that your business or organization will not take retaliatory actions against employees that raise concerns about the living wage? *
45. Do you certify that you will inform your employees that your business or organization is living wage certified upon approval of the application? *
46. Do you certify that you have the authority to represent this business or organization? *
47. Who from Orange County Living Wage assisted you in applying for living wage certification? *
48. Date Submitted *
MM
/
DD
/
YYYY
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Additional Terms