APPLICATION FOR CHILD LABOR EXEMPTION PERMIT
MINORS UNDER 16 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:______________
Hours of Employment: __________ to ___________ (show a.m. and p.m.)
Days of employment: Su M Tu W Th F Sa (circle applicable days)
|
EFF. DATE
EXPIRATION
DATE |
SPECIFIC EXEMPTION(S) SOUGHT:
[ ]employment at under 14 years of age.
[ ]employment before 7 a.m. or after 9 p.m.
[ ]employment for more than 8 hours a day/or more than 40 hours a
workweek.
[ ]employment during school hours on school days.
[ ]employment in a prohibited occupatoin. (Describe hazardous equip-
ment 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-80017-02b (3/93)