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Richmond Living Wage Certification Online Application

Employer Information

Name of Employer/Organization *

Address *

Address Line 1

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

Please provide a brief description of the organization or the mission statement: *

Qualifying Criteria

1. How many employees do you have? *

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

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

c. How many employees are not eligible to receive health insurance benefits? *

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

b. How many of the employees are minors? *

c. How many of the employees are temporary or project-based employees? *

d. How many of the employees receive tips as a significant part of their income? *

e. Other (please describe)

3. Please select the lowest rate paid to your employees, excluding only those eligible to be exempted (2A, 2B, 2C). *

at least $16 per hour
at least $14.50 per hour plus healthcare

Don't forget - tipped workers must be included in your employee wage consideration. Tipped workers' wages should be the average wage counting both the tipped minimum wage and tips.

4. If you have a group health plan, do you pay at least 50% of the employee's cost or at least $250/month for each employee?

Yes
No

a. If you give each employee a contribution toward health care, do you give each person at least $250/month?

Yes
No

5. 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 health, dental, or vision insurance but pay less than 50% of the cost or under $250/month? *

Yes
No

d. Do you provide child care assistance? *

Yes
No

e. Do you provide tuition assistance? *

Yes
No

f. Do you provide contributions towards retirement? *

Yes
No

If you answer yes to any of the parts of Question 5, someone from the Committee will follow up with you to determine the value of the additional qualifying benefits.

6. Do you hire independent contractors that you pay on an hourly basis? *

Yes
No

a. If yes, how many independent contractors do you regularly use?

b. Please describe your independent contractors job titles and/or roles.

Additional Information

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 any other benefits to meet our criteria? *

Yes
No

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

Yes
No

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

Yes
No

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

Yes
No

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

Yes
No

d. 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

Message

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