Home
Virginia Interfaith Center

804-643-2474 ext. 101

GIVE

About
- Faith Statements
- Updates
Get Certified
100 Certified Congregations
Charlottesville
- Application
- Certified Employers
Harrisonburg
Northern Virginia
- Application
- Certified Employers
Richmond
- Application
- Certified Employers
Statewide
- Application
- Statewide Certified Employers

Northern Virginia Living Wage Certification Online Application

Name of Employer/Organization *

Street Address *

City *

State *

Zip Code *

Phone *

Website *

Facebook

Please add your Facebook handle/page

Twitter

Please add your Twitter handle/page

Instagram

Please add your Instagram handle/page

Primary Contact *

First

Last

Primary Contact Job Title *

Primary Contact Email *

Media Contact (if different from Primary Contact) *

First

Last

Media Contact Email *

1. How many employees do you have? *

a. How many employees are eligible to receive health insurance benefits? *

b. How many employees who are eligible actually receive health insurance benefits? *

c. How many employees are no eligible to receive health insurance benefits? *

2. How many of the employees listed above are apprentices or interns? *

a. How many are minors? *

b. How many are temporary or project-based employees? *

c. Other (please describe)

b. Do you pay all of your employees at least $17.50 per hour?

If you have tipped employees, tips plus wages received from the employer must average at least $17.50/hour.

3. How much do you pay your employees per hour (excluding) those listed above in Question 2? *

4. Do you provide a vehicle for personal use after work hours?

Yes
No

a. Do you provide housing or a housing stipend to your employees?

Yes
No

b. Do you provide daily shift meals or food assistance to your employees?

Yes
No

c. Do you provide child care assistance?

Yes
No

d. Do you offer tuition assistance?

Yes
No

e. Do you offer employer-provided health care?

Yes
No

If you answer yes to any of these benefits, you will be asked to complete an application addendum.

5a. Do you hire independent contractors whom you pay on an hourly basis? *

Yes
No

b. How many independent contractors do you regularly use? *

c. If you answered yes to 5a, please describe their job titles/roles:

6. Do you provide an annual cost of living adjustment?

Yes
No

7. Did you increase wages to any employees to meet our criteria?

Yes
No

a. Did you increase health insurance benefits to meet our criteria? *

Yes
No

b. Did you increase other benefits to meet our criteria? *

Yes
No

8a. Do you certify that your organization embraces the Living Wage Concept? *

Yes
No

b. Do you certify that your employees are aware that you have applied for the Living Wage Certification? *

Yes
No

c. Did you certify that you are not withholding any information that could negatively affect this application? *

Yes
No

d. Do you agree that your business will not take retaliatory actions against employees that raise concerns? *

Yes
No

e. Do you certify that the information above is true and accurate to the best of your knowledge and that you have the authority to sign this application? *

Yes
No

Please upload your organization's logo | min size: 150px x 150px *

Click or drag a file to this area to upload.

If your organization does not qualify to be certified, the logo will not be used.

Signed *

First

Last

Title *

Date *

Single Line Text

Website

Facebook
Instagram
Twitter
Contact Us
Anonymous Employer Complaint Form