LABOR STANDARDS UNIT
220 French Landing Drive
Nashville TN 37243
-1002
844-224-5818
CHILD LABOR PARENTAL STATEMENT OF CONSENT
Date
In accordance with Tennessee Code Annotated § 50-5-105, (Employment of Minors 16 or 17 Years of Age),
permission is hereby granted for employment of between the hours
(Full Name of Minor)
of 10:00 p.m. and 12:00 o’clock midni
ght (12:00
a.m.)
not more than three (3) nights per week (Sunday
through Thursday) at
the
following place of business:
Company Name and Address
(Signature of Parent(s) or Legal Guardian(s)
SEAL
(Signature of Notary)
(Commission Expiration Date)
NOTE TO EMPLOYER: Notarized ORIGINAL of this form must be maintained in employee file at the place
of employment.
THIS FORM IS VALID UNTIL THE END OF THE SCHOOL YEAR DURING WHICH IT IS SUBMITTED OR UNTIL
TERMINATION OF THE MINOR’S EMPLOYMENT OR UNTIL THE MINOR REACHES THE AGE OF 18,
WHICHEVER COMES FIRST.
"The Tennessee Department of Labor and Workforce Development is an equal opportunity employer/program; auxiliary aids
and services are available upon request."
TTY: 1-800-848-0299
LB-0355 (Rev. 10-18)
RDA 11147
