Fillable YOUTH EXEMPTION REQUEST FORM (Colorado DORA)

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YOUTH EXEMPTION REQUEST FORM (Colorado DORA)

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The YOUTH EXEMPTION REQUEST FORM (Colorado DORA) form is 1 page long and contains:

  • 1 signature
  • 10 check-boxes
  • 25 other fields

Country of origin: US
File type: PDF

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Colorado Department of Regulatory Agencies (DORA) is responsible for professional licensing and consumer protection in Colorado USA.

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Colorado Division of Labor Standards and Statistics
633 17
th
Street, Suite 600
Denver, Colorado 80202-2107
Telephone (303) 318-8441
Fax (303) 318-8400
Toll Free (888) 390-7936
www.colorado.gov/cdle/labor
Office Use Only:
CLAIM #:
COMP
INVESTIGATOR:
DATE
RECEIVED:
June 2017
YOUTH EXEMPTION REQUEST FORM
Use this form to request an exemption from the Colorado Youth Employment Opportunity Act (CYEOA), C.R.S. § 8-12-101,
et seq. Fill the form completely; failure to do so will delay processing. If you have questions, please contact the Division at
303-318-8441 or cdle_labor_standards@state.co.us.
Name of Minor ______________________________________________ Date of Birth_________________ Age_______
Mailing Address____________________________________________________________________________________
City_________________________________________________ State_______________ Zip Code _________________
Telephone _________________________ Email Address ___________________________________________________
Relationship to Minor: ☐ Employer ☐Minor ☐Parent or Legal Guardian ☐School Official ☐Youth Employment Specialist
Name of Employer ___________________________________Owner or Supervisor’s Name _______________________
Mailing Address____________________________________________________________________________________
City_________________________________________________ State_______________ Zip Code__________________
Main Telephone _______________________________ Alternate Telephone____________________________________
Type of Industry ________________________________ Email Address _______________________________________
Minor’s Occupation/Position/Job Title __________________________________________________________________
Rate of Pay (per hour) $__________ Other Compensation (explain) ___________________________________________
I am requesting an exemption from CYEOA restrictions based on (check all that apply):
Please detail the reason(s) for this exemption request (use additional sheets if necessary):
Will the job be performed during school hours? ☐Yes ☐No
Name
Signature
Please allow up to 14 days for the Division to process this request. If approved, this exemption applies only to Colorado youth laws
and regulations. If your request conflicts with federal youth law, the Division will deny the request. For information on federal youth
standards, please contact the U.S. Department of Labor.
Age Limitations
Work Hour Restrictions
Prohibited Duties
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YOUTH EXEMPTION REQUEST FORM (Colorado DORA)

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Completed 20 July 2020

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