Application Form Testing Payments Zeffy - Orange County Living Wage

"*" indicates required fields

Date of Application

MM slash DD slash YYYY

2024 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.

Employers must reapply for Living Wage certification every two years.

Business / Organization Information

Application Type:*

First Time Application

Recertification

Name of Business or Non-profit*

Contact Person*

First Last Title

Physical Address of Business or Organization*

Street Address Address Line 2 City State ZIP Code

In what county is your office located?*

Mailing Address (if different than above)

Street Address Address Line 2 City State ZIP Code

What is the best email address to contact your business?*

What is the best email address for Orange County Living Wage to contact you personally?*

What is the main phone number for your business or organization?*

What is the best phone number to contact you directly?*

What is the URL for your business or organization’s website?

If you don't have a website, please provide a description of your business or organization.*

Employees & Wages

Note: You should count the following categories of employees in your answer BUT 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: orangecountylivingwage.org/definitions/

How many employees currently work for you? Include ALL employees regardless of status, e.g., full-time, part-time, tipped, temporary, etc.*

Please enter a number greater than or equal to 0.

How many employees fall into the following special categories?

Intern*

Please enter a number greater than or equal to 0.

Apprentice*

Please enter a number greater than or equal to 0.

Temporary working <90 days/yr*

Please enter a number greater than or equal to 0.

Minor working PT*

Please enter a number greater than or equal to 0.

New hire in probationary period <90 day*

Please enter a number greater than or equal to 0.

Are all current regular full- and part-time employees (excluding those in the special categories listed above) paid at least $17.65/hour?*

Note: For tipped, commissioned, and variable-pay employees, total compensation must equal at least $17.65/hour (or at least $16.15/hour with health insurance.)

How many tipped employees do you have?*

Please enter a number greater than or equal to 0.

How many commissioned employees do you have?*

Please enter a number greater than or equal to 0.

How many OTHER variable pay structure employees do you have, for example, employees that receive base pay + performance bonuses?*

Please enter a number greater than or equal to 0.

If you have tipped, commissioned, and variable pay employees, do you agree to allow an Orange County Living Wage team member to interview some employees to confirm rates with a portion of your staff? These interviews will be scheduled through you when it is convenient for you.*

Do you offer health insurance to all of your full- and part-time employees?*

Do you pay at least 50% of the employees’ premiums?*

Do you pay at least $16.15 per hour to all employees to whom you pay at least 50% of their health insurance?*

Do you pay at least $17.65 per hour to all employees to whom you do not provide health insurance?*

Raises & Benefits Increase

Did you raise wages and/or benefits to meet the 2024 requirements ($17.65/hr or $16.15/hr if health insurance offered by employer) to qualify as a new or renewing Orange County Living Wage employer?*

What was the average amount per hour of wage increase?*

Please enter a number greater than or equal to 0.

How many employees received a wage increase?*

Please enter a number greater than or equal to 0.

What is the total annual cost of the wage increase?*

Please enter a number greater than or equal to 0.

How many employees received an increase in benefits?*

Please enter a number greater than or equal to 0.

What is the total annual cost of the increase in benefits?*

Please enter a number greater than or equal to 0.

Did you raise wages in the interim year SPECIFICALLY to keep up with OCLW'S annual adjustment to the living wage?*

How many employees received a wage increase?*

Please enter a number greater than or equal to 0.

What is the total annual cost of the wage increase?*

Please enter a number greater than or equal to 0.

Additional Comments (optional)

Employer Attestation and Agreements

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?*

Do you agree to notify Orange County Living Wage if employee compensation falls below the Orange County Living Wage requirements in effect at the time you were certified?*

Do you agree that your business or organization will not take retaliatory actions against employees that raise concerns about the living wage?*

Do you certify that you will inform your employees that your business or organization is living wage certified upon approval of the application?*

Do you certify that you have the authority to represent this business or organization?*

Diversity

We are increasingly asked about the overall demographics of employees who are benefiting from a living wage. Please answer the following questions to the best of your ability.

Please tell us, to the best of your ability, the number of employees that fall into each of these gender categories.

Female

Please enter a number greater than or equal to 0.

Male

Please enter a number greater than or equal to 0.

Non-binary

Please enter a number greater than or equal to 0.

Please tell us, to the best of your ability, the number of employees that fall into each of these race or ethnicity categories.

Asian or Pacific Islander

Please enter a number greater than or equal to 0.

Black or African-American

Please enter a number greater than or equal to 0.

Hispanic or Latino

Native American or Alaskan Native

Please enter a number greater than or equal to 0.

White or Caucasian

Please enter a number greater than or equal to 0.

Multiracial or Biracial

Please enter a number greater than or equal to 0.

Are you a minority, worker or women-owned business?*

Check all that apply. If you are a not-for-profit business governed by a rotating board of directors, check none.

Minority-owned (The business is at least 51% owned and controlled by an individual(s) who is Black. Latino/Hispanic, Asian, or Pacific Islander, Indian or Alaskan Native)

Cooperative/worker owned

Women-owned (The business is at least 51% owned by women.)

None of the above / Not Applicable

Application Fees

Starting April 1, 2024, Orange County Living Wage will implement a new application fee to support the staff and infrastructure necessary to maintain and expand our programming. The fee structure: Employers with 0-9 employees: $50 Employers with 10-49 employees: $100 Employers with 50 or more employees: $200

Choose your payment method

You have two choices to pay, you can use Venmo by scanning the QR code or you can use a bank account, credit card, Apply Pay or Google Pay by using Zeffy.

Venmo

Zeffy (Credit card/bank/Apply/Google Pay)

If you're already on your mobile device, click HERE to get to Venmo.

Who from Orange County Living Wage assisted you in applying for living wage certification?*

Check all that apply.

Debbie Everly

Susan Romaine

Susan Attermeier

Allanah Hines

Megan Overbay

Itza Salazar

No One or Other

We publicize our certified employers on social media, in newsletters, on our website, and other outlets. If your application is approved, may we contact you for a quote or a photo? We offer, at no charge, the services of a professional photographer to take pictures that you can use as well.*

Is there anything else you want to tell us about your business or employees?