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.
536 East Wayne Avenue, Wooster, OH 44691
