APPLICATION FOR CHILD LABOR EXEMPTION PERMIT
MINORS 16 TO 17 YEARS OF AGE |
DEPT USE
ONLY |
NAME OF MINOR:___________________________AGE:_____BIRTHDATE:__________
Address:_______________________(city)___________(state)___(zip)_______
School minor attends: | PERMIT# |
EMPLOYER:______________________________Owner/Manager:_________________
Address:_______________________(city)___________(state)___(zip)_______
Phone:(___)___-____________ FAX:(___)___-____________
PROPOSED OCCUPATION:___________________________Rate of pay:___________
Description of duties:________________________________________________
|
APPROVED
OCCUPATION |
PROPOSED DATES OF EMPLOYMENT: Start:______________ End:______________
Days of employment: Su M Tu W Th F Sa (circle applicable days)
|
EFF. DATE
EXPIR. DATE |
SPECIFIC EXEMPTION SOUGHT:
[ ]Employment before 5:00 a.m. or after 11:00 p.m. while school is
in session.
[ ]Employment in a prohibited occupation.
Describe hazardous equipment or task (see Child Labor Brochure for
descriptions).________________________________________________________
______________________________________________________________________
Describe the minor's special talent, unique qualification or
special need for this employment:_____________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
What measures are being taken to protect the minor's health, education,
or welfare (i.e. safety precautions, tutorting, supervision, etc.)?___
______________________________________________________________________
______________________________________________________________________
|
EXEMPTION(S) |
I certify that all of the above statements are true and accurate.
Signature:_____________________________Relation to minor:_____________
(parent, guardian, school official, youth employment specialist)
Address:________________________(city)___________(state)___(zip)______
Phone:(___)___-____________ Date:_________________ | APPROVED BY |
Permit will be sent to parent, guardian, school official, or
youth employment specialist, and employer at address shown on the
application form. | DATE |
LI-80017-02c (3/93)