NOTE: This form is not an Employment Certificate.
The process for employing a minor, under the age of 18, involves a two-part process:
Applicant Information:
____________________________________________________ _______________ _____________ ______________
Name of minor Age Sex Date of birth
________________________________________________________________________ ________________________________
Physical address: city, state and zip code Telephone number
____________________________________________________ ____________________________________________________
Number of work hours per day Number of days per week
________________________ _________________________ _________________________ ________________________
Time shift begins Time shift ends Minors ages 14 and 15 only:
Prior to school days Time shift begins and ends during June 1 – Labor Day
Employer Information:
_____________________________________________________________________________________________________________
Name of employer (DBA)
_____________________________________________________________________________________________________________
Physical address — where work will be performed: city, state and zip code
____________________________________________________ ____________________________________________________
Employer’s telephone number Industry of employer
_____________________________________________________________________________________________________________
Job tasks to be performed by minor
_____________________________________________________________________________________________________________
Job tasks (continued)
____________________________________________________ ____________________________________________________
Name and title of employer representative Signature: Name of employer representative
Parent’s Consent Statement:
I, __________________________________________ , __________________ , ___________________ hereby give consent for
Signature of consenting parent or legal guardian Date Telephone number
____________________________________________________
, to be employed by the above named employer.
Name of child
NOTE: This form is not an Employment Certificate.
THIS FORM MUST BE COMPLETED AND SIGNED BY
AN EMPLOYER REPRESENTATIVE OF THE EMPLOYING FIRM.
March 2020 PR1021
A
pplication to Employ Minors Under Age 18
OFFICE OF WORKFORCE DEVELOPMENT
1.Fillintheinformationbelowandprintthecompletedform.
2.Aftertheemployercompletesandsignsthisapplication,theminormusthavea
par entsigntheParent’sConsentStatementsectionbelow.
3.Emailthecompletedandsignedapplication,alongwithproofofage
(examples:birthcertificate,driver’slicense, etc.)tolaborprograms@lwc.la.gov
4.Whentheapplicationhasbeenapproved,theemployerwillbenotifiedvia
emailfromtheLWCOfficeofWorkforceDevelopment.
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