Brown County WI Clerk\svj Revised 7/25/19
W:word\wkpermit\emplettr.doc
THIS FORM MAY BE COPIED AND/OR REPRODUCED
Business Name:
Address:
City/State/Zip:
Phone Number:
REQUEST FOR CHILD LABOR PERMIT
(Minor’s - bring with you the following required items: a birth record, actual Social Security Card, Letter of
Employment including the parent’s permission, and a $5 permit fee.)
To whom it may concern:
(Minor’s name) _____________________ ____ will be employed by (Business
name) _______________________________ ___ as a
(Job title) ________________________ approximately ______ hours per week. He/she
will be performing such duties as:
______________________________________________________________________
____________________________________________________________________.
______________________________
Manager or Supervisor’s Signature
(Parent must complete the lower section)
As parent and legal guardian of (minor’s name) _______________________________,
I give him/her permission to perform the stated job and duties at the business listed
above.
______________________________
Parent’s Signature
