OL-C-41 (Rev. 01/09)
STATE OF LOUISIANA
WORKFORCE COMMISSION
OFFICE OF REGULATORY SERVICES
To obtain a vacation work permit or employment certificate, the minor must bring this properly completed form, along with suitable proof
of age, to the parish or city school superintendent.
INTENTION TO EMPLOY
MINORS UNDER 18
The certificate or vacation work permit will be denied unless all conditions regarding hours, type of employment, etc., are in accordance
with provisions of R.S. 23:151-234.
In accordance with provisions of R.S. 23:151-234, employers who employ minors illegally are subject to civil money penalties and/or
criminal prosecution which may result in criminal fines and jail sentences.
Name of Minor _______________________________________ Name of Employer___________________________________________
Address _____________________________________________ Physical Address_____________________________________________
(Where work will be performed)
Age _______ Sex_______ Date of Birth___________________ Employer’s Telephone No._____________________________________
Minor will work _____ hours per day; ______ days per week; Industry of Employer_________________________________________
Shift will begin at ______ and end at _______ prior to school days. Occupation of Minor _________________________________________
(
time) (time) (Job tasks to be performed)
Shift will begin at ________ and end at _________ prior to non-school days.
(time) (time)
___________________________________________________ ____________________________________________________________
Please Print Name & Title of Employer Representative Signature of Employer Representative
=========================================================================================================
PARENT'S CONSENT STATEMENT
I, ____________________________________, _________, _______________ hereby give consent for ___________________________________
(signature of consenting parent or legal guardian) (date) (telephone number) (name of child)
to be employed by the above named employer.
THIS FORM MUST BE EXECUTED AND SIGNED BY AN OFFICER OF EMPLOYING FIRM.
