APPLICATION FOR MINOR WORK PERMIT

3331.02 ORC 4109.02 ORC

STUDENT / APPLICANT INFORMATION

Name of Student / Applicant in full:	Sex:

Male

Grade Level:

Female

Proof of Age (Type of document):

Address of Student /Applicant:

Age:	Date of Birth:	Physician’s certificate:

Submitted with this application

Valid physician’s certificate on file

School District:

Parent or Guardian:

Building:

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.
X

Signature of Parent or Guardian

Date Signed

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.

I HEREBY CERTIFY THAT I HAVE EXAMINED AND APPROVED THE ABOVE NOTED DOCUMENTARY PROOF OF AGE.

X

Superintendent / Chief Adminstrative Officer / Designated Issuing Officer

Name of Office

Address of Office

PLEDGE OF EMPLOYER

Name of Firm:	Telephone Number at Minor’s Work Location:

Address of Student /Applicant’s Place of Employment, Job Site, or Work Location:

Specific Nature of Employment:

Employer’s Tax ID Number (9 digits). THIS FIELD IS MANDATORY

No. of Days Per Week: Hours Per Day:	Starting Time:

1	2	3

Quitting Time:

4

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?

YES

NO

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

X

Signature of person authorized to sign for employer	Date signed	Telephone number

Address of employer if different from minor’s place of employment

LAWS COM 0000 (Replaces Ohio Form II & III)

E-Mail address
(Optional- if employer wants notification in case of revocation)

PHYSICIAN’S CERTIFICATE FOR MINOR WORK PERMIT

3331.02 ORC 4109.02 ORC

APPLICANT INFORMATION

Name of Student / Applicant in full:

Date of Birth:	Height:	Weight:	Color of Hair:

Sex:

Male	Female

Color of Eyes:

ft.	in.	lbs.

Distinguishing Characteristics, if any:

School District:

Parent or Guardian:

Building:

Parent or Guardian Telephone Number:

PHYSICIAN’S APPROVAL

THE UNDERSIGNED HEREBY CERTIFIES THAT THEY HAVE THOROUGHLY EXAMINED THE ABOVE NAMED APPLICANT WHO WAS BORN ON THE DATE STATED ABOVE, AND WHO MEETS THE DESCRIPTION GIVEN HEREON, AND THAT SAID PERSON;

NOTE: IF WORK SHOULD BE LIMITED TO A CERTAIN TYPE OF EMPLOYMENT, THE PHYSICIAN MUST MARK THIS FORM ACCORDINGLY IN THE AREA BELOW.

IS	IS NOT	Limited Certificate:	YES	NO

IN THEIR OPINION PHYSICALLY FIT TO PERFORM THE WORK OF ANY EMPLOYMENT NOT FORBIDDEN BY LAW TO A PERSON OF THIS AGE AND SEX.

If Marked YES;
Employment should be Limited to Work Specified Below:

X
Physician’s Signature

Date Signed

LAWS COM 0000 (Replaces OHIO FORM V)