State Form 896 - Intention To Employ / A1

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NOTE: This card must be presented by the minor to
the issuing officer in their school before a certificate
INTENTION TO EMPLOY / A1
will be issued. For employer’s protection, the minor
must also present an acceptable proof of age to
State Form 896 (R6 / 6-99)
obtain an employment certificate. The hours minor
may work are shown on the reverse side.
Name of minor (intend to employ)
Date
Residential street address
City, state, ZIP code
FRONT
Days of week
Hours per week
Is minor on school-directed Vocational Education
Hours per day
(appr.)
(appr.)
(appr.)
Program with your firm?
Yes
No
List exact duties
Name of business
Telephone no.
Type of business (Mfg., Process,
Retail, Restaurant)
Street address
City, state, ZIP code
Signature of employer’s rep.
Signature of minor
Signature of parent or guardian
Fold here
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