NOTE: This form is not an Employment Certificate.
The process for employing a minor, under the age of 18, involves a two-part process:
1. After the employer completes this application, the minor must have a parent sign the Parent’s
Consent Statement section below. Bring the form, along with proof of age (examples: birth certificate,
driver’s license, etc.) to an authorized issuing location, typically the School Board or high school).
2. The authorized official will then issue an Employment Certificate, providing all conditions regarding
hours, type of employment, etc. are in accordance with R.S. 23:151-234.
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.
July 2013 PR1021
A
pplication to Employ Minors Under Age 18
OFFICE OF WORKFORCE DEVELOPMENT
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