41Dt.ll2DRC

APPLICATION FOR MINOR WORK PERMIT	3331.0ZORC

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Name of Student I Applicant Infull:	Sex:
DMale DFemale

I_, D	D

Proof of Age (Type of document):	Age:	Date of Birth:	Physician's certificate:

Grade Level:

.__	_ 	_ Address of Student /Appllcant:

.  D .I_._

_ 	_

Submitted with	VaBd phy1lcian'1 this application	certificate on file

Sctiool Dlstr1ct:	Building:

 	
Parent or Guardian:	Parent or Guardian Telephone Number:

 	
Addresa of Parent or Guardian:

IHEREBY CERTIFY THAT TO THE BEST OF MY KNOWLEDGE AND BELIEFTHE ABOVE STATEMENTS ARE TRUEANO THAT THE MINOR NAMEDABOVE \NILL WORK WITH MY APPROVAL

IHEREBY CERTIFY THAT IHAVE EXAMINEDANDAPPROVEDTHE ABOVE NOTED DOCUMENTARY PROOF OFAGE.

Signature of Parent or Guardian

Date Signed

THE NUMEER OF HOURS OR OAl'S AND THE TIMES DISPl.AYED BELOW OR ON TI-IE FINAL

 	mr

PERMIT ARE FOR REGUl.RORVP POSES ONLYANDARENOT TO BE CONS1RUED IN
WAYOR MANNER TO BEINDICATIVE OF A OONTRACTl!El"M;ENANEMPLOYER ANO THE EMPLOYEE.	-

laR&	- JIJCkl 41-:	IY)"tiY/lJb

IPLEDGE OF IMPlOY'ER
Name of Firm:

Addl'Bls of Student /Appl cant's Place of Employment, Job Sita, or Wort Location:

Speclllc Nature of.Employment:

Md-O\a

Telephone Number at Minor's Work Location:

Employer's Tax ID Number (9 digits). THIS FIELDIS MANDATORY

IF MINOR WORKS A VARIED OR IRREGULAR SCHEDULE, ENTER

I

- "REPRESENTATIVE" TIMES IN

D YES

·ITEMS

1THRU 4. ARE HOURS

I

No. of Daya Per Week: Hours Per Day:	Staring Time:
(1)	I(3)	I ...........

Quitting Time:
.! @)

TO BE WORKED WITHINTHE LIMITS OF THE lAWl

D 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 VVllH SEC. 4109.42 ORC. THE EMPLOYMENT WILL BECOME EFFECTIVE AS SOON AS THE NECESSARY AGEAND SCHOOLING CERTIFICATE IS VERIFIED BY THE EMPLOYER. THE EMPLOYER AGREES TO PERMIT THE CHILD TO ATTEND PART TIME SCHOOL WHEN SUCH IS AVAI LABLE AND TO NOTIFY THE SCHOOL WITHIN FIVE DAYS AFTER THE EMPLOYMENT OF THE CHILD TERMINATES.

-------	I I 	
Signature of pei.on authorized to signfor employer	Date signed	Telephone number

 	

Address of employer Ifdifferent from minor'•place of employment
COM ODOG (1!1pl••Chlo,11111111 110

E-Mall addre11
(Optional·If employer wanta notlftcaon In case of revocation)

PHYSICIAN'S CERTIFICATE FOR MINOR WORK PERMIT	
IAPPLICANT INFORMATION
Name of Stud9nt IAppllclnt Infull:

ca..of Birth:

DMale	DFemale
Height:	Waight	Color of Hair:	Color of EYK

=========!;I--

ft.  --'-"-·.I .I.---,-b-l-..I I	_ .I I  ---

School Dl1lr1d:

P1rent or Gu1rdl1n:

Bulldlng:

Perent or Gu1rdl1n Telephone Number:

 	

PHVllCIAN'I APPROVAL

THE UNDERS GNED HEREBY CERTIFIESTHAT THEY HAVE THOROUGHLY EXAMINEDntE ABOVE NAMEDAPPLICANT VVHO WAS BORN ON THE DATE STATEDABOVE,ANDWHO MEETS THE DESCRIPTION GIVEN HEREON, ANO THAT SAID PERSON;

NOTE:IFWORK SHOULD BELIMrrED TOA CERTAIN TYPEOF EMPLOYMENT.THE PHYS CIAN MUST MARK THIS FORM ACCORDINGLYIN THEAREA BELOW.

D IS

D IS NOT

Limtl9d Certificate:

D YES

IN THEIR OPINION PHYSICALLY FIT TO PERFORM THE'NORI< OF ANY EMPLOYMENT NOT FORBIDDEN BY LAWTO A PERSON OF THISAGE ANDSEX.
Ix 	

If Mlrked YES;
Employment should be Umlted to Vllori< Specllled Below: