Form Ca-7 - Combined Offer Of Employment And Work Permit/age Certificate Ca-7 For Minors 16 And 17 Years Of Age
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1
2State of Michigan
Permit Number for School Use
Combined Offer of Employment and Work Permit/Age Certificate
(optional)
CA-7 for minors 16 and 17 years of age
Employer Information:
- The employer must have a completed front and back yellow work permit form on file before a minor begins work.
- The employer or an employee who is 18 years of age or older must provide competent adult supervision at all times.
- The employer of the minor must comply with federal, state, and local laws and regulations including nondiscrimination against any
applicant or employee because of race, color, religion, national origin or ancestry, age, gender, height, weight, marital status, or disability.
- The employer must return the work permit to the issuing officer upon termination of the minor’s employment.
Directions: Please type or print using black ink pen. ALL FIELDS MUST BE COMPLETED. Back of this form must have summary of requirements.
Section I: Each Box must be Completed by Minor Applicant and Parent/Guardian
Name of Minor:
Address:
City:
ZIP:
Age:
Date of Birth Month/Day/Year:
Last Four Digits of Social Security Number:
Contact Telephone Number for Minor:
Name of School (present or last attended):
Address:
City:
ZIP:
Type of Business (i.e., fast food, manufacturing):
Last Grade Completed:
School Status (check one):
[ ] in school
[ ] home school
[ ] online/Cyber/Virtual school [ ] not attending school
Signature of Minor:
Name of Parent/Guardian (circle one):
Parent/Guardian Telephone:
(x)
Section II: Each Box must be Completed by the Employer - Offer of Employment
Name of Business :
Address:
City:
ZIP:
Earliest Starting Time 6:00 a.m.
Latest Ending Time 10:30p.m.
Hours per Day:
Number of Days per Week:
Total Hours of Employment:
No earlier than 6:00 am
No later than10:30 pm(Sun-Thurs)
No more than 24 when school in
No later than11:30 pm (Fri-Sat)
session; No more than 48 when school
No earlier than 6:00 am
No more than 8
No more than 6 per week
not in session
Applicant’s Job Title:
Hourly Wage:
:
:
Name Job Duties/Tasks to be Performed by Minor
Name Equipment/Tools to be Used by Minor
Will the minor be working under an hours deviation granted by the Michigan Department of Education?
[ ] No
[ ] Yes
If yes, attach the Individual Application for Hours Deviation for 16 and 17 Year Old Minors along with this original yellow CA-7 and mail to:
, for approval
MDE/OCTE P.O. Box 30712, Lansing, Michigan 48909
Signature of Employer:
Title:
Telephone:
Date:
(x)
Section III: Each Box must be Completed by School’s Issuing Officer – Must be Signed by the Issuing Officer to be Valid
Number of Work Hours
Evidence of Age Confirmed by (issuing officer checks one):
per Week, when School
This is to certify that:
is in Session:
(1) the minor personally appeared before me,
No more than 24
(2) this form was properly completed,
[ ] Birth Certificate
[ ] Certificate of Arrival in the U.S.
hours per week
(3) listed job duties are in compliance with state and
federal laws and regulations,
Number of Work Hours
[ ] Driver’s License
[ ] Hospital Record of Birth
(4) listed hours are in compliance with state and
while school is not in
federal laws and regulations,
session (Summer,
[ ] School Record
[ ] Baptismal Certificate
(5) this form was signed by student and employer,
Spring, Xmas vacation):
and I authorize the issuance of this work permit.
No more than 48
[ ] Other (describe)
hours per week
Name of School District:
Printed Name of Issuing Officer:
Title:
Address:
City, State, ZIP:
Signature of Issuing Officer:
Issue Date:
Telephone Number:
(x)
Must Print front and back on Yellow Paper.
Form CA-7 (revised 10/18/2011) Combined Offer of Employment & Work Permit and Age Certificate
Instructions for completing CA-7 must be printed on back of form to be valid.
Must submit original yellow front and back CA-7 when submitting Individual Application for Hours Deviation form.
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