Fillable Work Permit Application Instructions

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Work Permit Application Instructions

On average this form takes 16 minutes to complete

The Work Permit Application Instructions form is 3 pages long and contains:

  • 3 signatures
  • 4 check-boxes
  • 50 other fields

Country of origin: US
File type: PDF

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Work Permit Application Instructions
Please fill out the information in the order listed below. Work
permits will not be issued if all sections have not been completed.
Step 1: Student/Applicant Information
This information is filled out by the parent/guardian of the student and must
have a parent/guardian signature. The Director’s signature will be last step
of the work permit process.
Step 2: Pledge of Employer
This information must be filled out by your employer. Please note that the
Employers’ Tax ID Number field is MANDATORY.
Step 3: Physician’s Certificate for Minor Work Permit
This information is filled out and signed by the student’s doctor. Athletic
physicals will be accepted if dated within one (1) year.
FINAL STEP
Bring the completed forms and a copy of your birth certificate or driver’s
license to Ginger Rife in the C-TEC front office to obtain your work permit.
APPLICATION FOR MINOR WORK PERMIT
Name of Student / Applicant in full:
Date of Birth:
Address of Student /Applicant:
Age:
Sex:
Male Female
Grade Level:
PLEDGE OF EMPLOYER
Name of Firm:
Address of Student /Applicant’s Place of Employment, Job Site, or Work Location:
School District:
Building:
Parent or Guardian:
Parent or Guardian Telephone Number:
Address of Parent or Guardian:
I HEREBY CERTIFY THAT TO THE BEST OF MY KNOWLEDGE AND
BELIEF THE ABOVE STATEMENTS ARE TRUE AND THAT THE MINOR
NAMED ABOVE WILL WORK WITH MY APPROVAL.
I HEREBY CERTIFY THAT I HAVE EXAMINED AND APPROVED THE
ABOVE NOTED DOCUMENTARY PROOF OF AGE.
Signature of Parent or Guardian
Date Signed
THE UNDERSIGNED HEREBY AGREES TO EMPLOY THE ABOVE NAMED CHILD IN ACCORDANCE WITH LAWS REGULATING THE
EMPLOYMENT OF MINORS. THE EMPLOYER FURTHER AGREES TO GIVE MINOR A COPY OF THE WAGE AGREEMENT IN ACCORDANCE
WITH SEC. 4109.42 ORC. THE EMPLOYMENT WILL BECOME EFFECTIVE AS SOON AS THE NECESSARY AGE AND SCHOOLING CERTIFICATE
IS VERIFIED BY THE EMPLOYER. THE EMPLOYER AGREES TO PERMIT THE CHILD TO ATTEND PART TIME SCHOOL WHEN SUCH IS
AVAILABLE AND TO NOTIFY THE SCHOOL WITHIN FIVE DAYS AFTER THE EMPLOYMENT OF THE CHILD TERMINATES
Proof of Age (Type of document):
Physician’s certificate:
Valid physician’s
certificate on file
Submitted with
this application
Superintendent / Chief Adminstrative Officer / Designated Issuing Officer
Name of Office
Address of Office
Telephone Number at Minor’s Work Location:
Specific Nature of Employment:
No. of Days Per Week: Hours Per Day: Starting Time: Quitting Time:
IF MINOR WORKS A VARIED OR
IRREGULAR SCHEDULE, ENTER
“REPRESENTATIVE” TIMES IN
ITEMS 1 THRU 4. ARE HOURS
TO BE WORKED WITHIN THE
LIMITS OF THE LAW?
4
Signature of person authorized to sign for employer
Address of employer if different from minor’s place of employment
Telephone number
E-Mail address
(Optional- if employer wants notification in case of revocation)
Date signed
STUDENT / APPLICANT INFORMATION
YES
NO
LAWS COM 0000 (Replaces Ohio Form II & III)
3331.02 ORC
4109.02 ORC
321
Employer’s Tax ID Number (9 digits). THIS FIELD IS MANDATORY
X X
X
THE NUMBER OF HOURS OR DAYS AND THE TIMES DISPLAYED BELOW OR ON THE FINAL
PERMIT ARE FOR REGULATORY PURPOSES ONLY AND ARE NOT TO BE CONSTRUED IN
ANY WAY OR MANNER TO BE INDICATIVE OF A CONTRACT BETWEEN AN EMPLOYER
AND THE EMPLOYEE.
Michelle Snow, Director
150 Price Road, Newark, OH 43055
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PHYSICIAN’S CERTIFICATE FOR MINOR WORK PERMIT
Name of Student / Applicant in full:
Date of Birth:
Distinguishing Characteristics, if any:
Sex:
Male
Female
PHYSICIAN’S APPROVAL
School District:
Building:
Parent or Guardian:
Parent or Guardian Telephone Number:
THE UNDERSIGNED HEREBY CERTIFIES THAT THEY HAVE
THOROUGHLY EXAMINED THE ABOVE NAMED APPLICANT WHO
WAS BORN ON THE DATE STATED ABOVE, AND WHO MEETS THE
DESCRIPTION GIVEN HEREON, AND THAT SAID PERSON;
NOTE: IF WORK SHOULD BE LIMITED TO A CERTAIN TYPE OF
EMPLOYMENT, THE PHYSICIAN MUST MARK THIS FORM
ACCORDINGLY IN THE AREA BELOW.
Physician’s Signature
Date Signed
IS NOTIS
Limited Certificate:
If Marked YES;
Employment should be Limited to Work Specified Below:
APPLICANT INFORMATION
3331.02 ORC
4109.02 ORC
Height: Weight: Color of Hair:
ft. in.
lbs.
Color of Eyes:
IN THEIR OPINION PHYSICALLY FIT TO PERFORM THE WORK OF
ANY EMPLOYMENT NOT FORBIDDEN BY LAW TO A PERSON OF
THIS AGE AND SEX.
X
YES NO
LAWS COM 0000 (Replaces OHIO FORM V)
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Work Permit Application Instructions

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Completed 26 April 2021

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