Application For Employment Of A Minor

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Mail To:
Arkansas Dept of Labor
Labor Standards Section
Arkansas Department of Labor
10421 West Markham
APPLICATION FOR EMPLOYMENT OF A
Little Rock, Arkansas 72205-2190
Ph 501-682-4500 fax 501-682-4506
MINOR
TDD (800) 285-1131
INSTRUCTIONS
SECTION 1
INSTRUCTIONS:
1. All sections must be completed before submitting the application. If all sections are not completed, the application will be denied.
2. As a means of establishing age, please submit a copy of one of the following documents with the application:
a) Certificate of Birth; b) Driver’s License; c) State or Federal I.D. card d) notarized copy of school record listing the minor’s name and date
of birth
3. The parent/guardian/custodian, child and the employer must sign the application or the application will be denied.
NOTE: A WORK PERMIT IS NOT REQUIRED FOR A MINOR 16 YEARS OF AGE. HOWEVER THERE ARE FEDERAL LAWS THAT LIMIT THE
JOBS THESE MINORS CAN PERFORM. FOR MORE INFORMATION PLEASE VISIT
SECTION 2
Statement of Parent, Guardian Or Custodian
I, the undersigned, hereby affirm that I am the __________________________of___________________________________________ now residing at
(Parent, Guardian or Custodian)
(First Name)(Middle Name)(Last Name)
________________________________________,___________________________,___________________,_________________,______________
(Street and Number)
(City)
(County)
(State)
(Zip Code)
and that _____________was born in ________________________,__________________________,________________ on the _____________ day of
)
(He/She)
(City)
(County)
(State
_______________________,
___________ and is now ____________years of age. School currently attending or last attended:
20
(Month)
(Year)
______________________________________________________ , _______________________________________________________
(Name Of School)
(Location)
I am willing that ________be so employed as stated in Section 3 of the application and ask that an employment certificate be issued as provided by law.
(He/She)
_____________________________________
_________________________________________ ________________________________________
(Signature of Parent/Guardian/Custodian)
(Printed Name of Parent/Guardian/Custodian)
(Signature of Minor)
SECTION 3
Intention to Employ
This section is to be completed in full and signed by the employer. Information must be provided or permit will not be issued
.
The undersigned intends to employ:
________________________,______________________________,_________________,_______________
in the capacity of
Name of Minor
Address
City
State
________________________in the_______________________ industry for __________days per week ,________hours per day on the following days:
Occupation
Type of business
(Complete start and end times for only the days that apply)
Mon: Start_________ End___________ Tues: Start___________ End___________ Weds: Start___________ End___________ Thurs: Star t__________ End__________
Fri: Start__________ End___________ Saturday: Start__________ End____________ Sunday: Start__________ End____________
Employment during Vacation Periods?
Yes
No
Employment during school year
Yes
No
If the minor’s schedule will vary, list the earliest possible beginning time and the latest possible ending time. Please note that Arkansas law allows a minor
14 and 15 years of age to work until 7:00 p.m. on nights that precede a school day and until 9:00 p.m. on nights that do not precede a school day. If your
business is subject to the Fair Labor Standards Act, a minor may not be employed: 1) during school hours; 2) before 7:00 a.m. or after
7:00p.m., except June 1 through Labor Day, when the hour is extended to 9:00 p.m.; more than three (3) hours a day on a school day, including
Fridays; 4) more than eight (8) hours a day on a non-school day; 5) more than eighteen (18) hours a week during a school week; 6) more than
forty (40) hours a week during non-school weeks. To obtain additional information on Federal child labor laws, you will need to contact the U.S,
department of Labor at (501) 223-9114, or visit
. Failure to comply with these regulations will result in the application being
denied.
The undersigned intends to employ the above mentioned minor immediately upon receipt of a certificate issued by the Arkansas Department of Labor and
agrees to comply with the provisions of the Arkansas Statutes and the Fair Labor Standards Act relating to the employment of minors.
_________________________________________________, __________________________, ____________________, __________________,________________
Name of Business/Employer
Mailing Address
City
State
Zip
_________________________________________________________ _________________________________________________ _______________________________________________
Signature of Employer or Authorized Agent
Printed name of Employer or Authorized Agent
Employers Telephone Number (Area Code First)
REMINDER: Proof of age must be attached to application or permit will not be issued.
Office Use:
Approved ____________Denied ____________Date_____________
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