Form Llc-75 - Parental Acknowledgement Of Minor'S Duties And Hours Of Employment printable pdf download

Form Llc-75 - Parental Acknowledgement Of Minor'S Duties And Hours Of Employment

PARENTAL ACKNOWLEDGEMENT

DEPARTMENT OF LABOR & INDUSTRY

OF MINOR’S DUTIES AND HOURS

BUREAU OF LABOR LAW COMPLIANCE

OF EMPLOYMENT

(Must be completed for minors under 16 years of age)*

(This section to be completed by the employer.)

The undersigned parent or legal guardian of

, age

(name of minor)

hereby acknowledges and understands that this minor’s employment with

, commencing

, will consist of the following duties and hours:

(name of employer)

(date)

(This section to be completed by the employer.)

Duties of minor (e.g., cashier, food service,

Hours of work:

lifeguard, sales clerk, etc.)

Sunday

.m.-

.m.

Monday

.m.-

.m.

Tuesday

.m.-

.m.

Wednesday

.m.-

.m.

Thursday

.m.-

.m.

Friday

.m.-

.m.

Saturday

.m.-

.m.

Other/additional hours (include explanation):

□

(

additional sheet(s) attached)

(To be signed by minor’s parent or legal guardian.)

I hereby acknowledge that I understand the above duties and hours to be worked by the above-named

minor for this employer and grant permission for this employment. This statement is made subject to the

provisions of 18 Pa. C.S. § 4904 (relating to unsworn falsifications to authorities).

□

Parent of

□

(Printed name of parent or legal guardian)

(Name of minor)

Legal guardian

(Signature of parent or legal guardian)

(Date)

* This form is required to be completed by the parent or legal guardian of a minor employee under 16 years of age pursuant to

Section 8(a)(2)(ii) of the Child Labor Act, and the original copy must be kept by the employer at the workplace along with other

records of the minor’s employment required by Section 8(d).

Auxiliary aids and services are available upon request to individuals with disabilities.

Equal Opportunity Employer/Program

LLC-75 01-13

Form Llc-75 - Parental Acknowledgement Of Minor'S Duties And Hours Of Employment

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