Please enable JavaScript in your browser to complete this form.Name of Employer/Organization *Street Address *City *State *Zip Code *Phone *Website *FacebookPlease add your Facebook handle/pageTwitterPlease add your Twitter handle/pageInstagramPlease add your Instagram handle/pagePrimary Contact *FirstLastPrimary Contact Job Title *Primary Contact Email *Media Contact (if different from Primary Contact) *FirstLastMedia 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)3. Do you pay $17.50 per hour or more to all of your employees, except those listed above in Question 2? *YesNob. What are the lowest wages you pay your employees?This will help determine the level of certification for which you qualify. Please complete Questions 4 and 5.4. Do you provide a vehicle for personal use after work hours?YesNoa. Do you provide housing or a housing stipend to your employees?YesNob. Do you provide daily shift meals or food assistance to your employees?YesNoc. Do you provide child care assistance?YesNod. Do you offer tuition assistance?YesNoe. Do you offer employer-provided health care?YesNoIf 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? *YesNob. 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?YesNo7. Did you increase wages to any employees to meet our criteria?YesNoa. Did you increase health insurance benefits to meet our criteria? *YesNob. Did you increase other benefits to meet our criteria? *YesNo8a. Do you certify that your organization embraces the Living Wage Concept? *YesNob. Do you certify that your employees are aware that you have applied for the Living Wage Certification? *YesNoc. Did you certify that you are not withholding any information that could negatively affect this application? *YesNod. Do you agree that your business will not take retaliatory actions against employees that raise concerns? *YesNoe. 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? *YesNoPlease 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 *FirstLastTitle *Date *EmailSubmit
