Fillable Permission to Employ Form: Instructions (Virginia Department of Motor Vehicles)

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Permission to Employ Form: Instructions (Virginia Department of Motor Vehicles)

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Virginia Department of Labor and Industry Division of Labor and Employment Law
Permission to Employ Form: Instructions
All forms related to the employment certificate process can be obtained at our website at
http://www.doli.virginia.gov/ through the link on the left sidebar titled “Request a Permit”.
THE YOUTH SHOULD NOT BEGIN THE APPLICATION PROCESS UNTIL HE HAS A
FORMAL OFFER OF EMPLOYMENT
All fields should be completed, if the field is not applicable to your child, please write “N/A” in
the field. If your child is homeschooled, please indicate in the School field by writing
“Homeschooled”.
The parent/guardian/custodian is required to have this form notarized, by a notary commissioned
to operate in the state of Virginia, with accompanying notary seal and signature, before
submitting.
The Employer Intent to Employ form, which must be completed by the employer, must be
submitted at the same time as this form. An employment certificate will not be issued until we
receive both original forms. Faxed or e-mailed copies will not be accepted.
If you have questions relating to the employment certificate process, please contact our office at:
Virginia Department of Labor and Industry
Central Virginia Regional Office
1570 East Parham Road
Richmond, Virginia 23228
(804) 371-3104 ext. 131
Please Print Clearly
NAME OF MINOR:
PERMISSION FOR EMPLOYMENT
(In accordance with Sections §40.1-84 & §40.1-92 Code of Virginia)
I consent to my child’s employment as indicated below:
COMMONWEALTH OF VIRGINIA
TO BE EMPLOYED AT:
PHYSICAL ADDRESS OF THE EMPLOYER:
PARENT/GUARDIAN/CUSTODIAN NAME
PHONE #:
WORK/CELL #:
COMMONWEALTH OF VIRGINIA
DEPARTMENT OF LABOR AND INDUSTRY
1570 EAST PARHAM ROAD
RICHMOND, VIRGINIA 23228
City/County of
(Date) (Name of Parent)
(Notary)
Commission Expires:
Appeared before me and signed the Permission for Employment Form on
DATE OF BIRTH:
EMAIL:
PARENT/GUARDIAN/CUSTODIAN
(Parent/Guardian/Custodian Signature)
(SIGN ONLY IN THE PRESENCE OF NOTARY)
Date
(THIS FORM MUST BE NOTARIZED)
First Last MI
Sex: F M (
Circle One)
NAME OF SCHOOL ATTENDING:
(Post Office Boxes Not Accepted)
Date
Date
Day Month Year
ADDRESS:
Street City State Zip
ADDRESS:
Street City State Zip
ADDRESS:
Street City State Zip
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Permission to Employ Form: Instructions (Virginia Department of Motor Vehicles)

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Completed 10 September 2020

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