State Of Michigan Combined Offer Of Employment And Work Permit/age Certificate Ca-6 For Minors Under 16 Years Of Age printable pdf download

Permit Number for School Use

State of Michigan

Combined Offer of Employment and Work Permit/Age Certificate

(optional)

CA-6 for minors UNDER 16 years of age

Employer Information:

- The employer must have a completed work permit form on file before a minor begins work.

- The employer must provide competent adult supervision at all times.

- The employer of the minor must comply with federal, state, and local laws and regulations including nondiscrimination against any

applicant or employee because of race, color, religion, national origin or ancestry, age, gender, height, weight, marital status, or disability.

- The employer must return the work permit to the issuing officer upon termination of the minor’s employment.

Directions: Please type or print using black ink pen. Back of this form must have summary of requirements to be valid.

Section I: Each Box must be Completed by Minor Applicant and Parent/Guardian

Name of Minor (First, Middle, Last):

Address:

City:

ZIP:

Age:

Date of Birth Month/Day/Year:

Last Four Digits of Social Security Number:

Contact Telephone Number for Minor:

Name of School (present or last attended):

Address:

City:

ZIP:

(i.e.

Type of Business

, fast food, manufacturing

Last Grade Completed:

School Status (check one):

[ ] in school [ ] home school [ ] on-line/virtual/cyber school [ ] not attending school

Signature of Minor:

Name of Parent/Guardian (circle one):

Parent/Guardian Telephone Number:

(x)

Section II: Each Box must be Completed by the Employer - Offer of Employment

Name of Business:

Address:

City:

ZIP:

Earliest Starting Time 7:00 a.m.

Latest Ending Time 7:00 p.m.

School Days

Not more

No more than:

Non School Days

3 hours a day, after school, on school

than 6

day Monday – Friday

No More than

Labor Day – June 1

No Earlier than 7:00 am

7:00 pm (

)

No more than 8

days per

3 hours a day

June 1 – Labor Day

No Earlier than 7:00 am

9:00 pm (

)

hours a day on

week

Monday-Friday

40 hours a week during non school

non school day

weeks

Applicant’s Job Title:

Hourly Wage:

Name Job Duties/Tasks to be Performed by Minor:

Name Equipment/Tools to be Used by Minor:

Signature of Employer:

Title:

Telephone:

Date:

(x)

Section III: Each Box must be Completed by School’s Issuing Officer – Must be Signed by the Issuing Officer to be Valid

Number of Hours in School

Evidence of Age Confirmed by (issuing officer checks one):

per Week, when School is

This is to certify that:

in Session:

(1) the minor personally appeared before me,

[ ] Birth Certificate

[ ] Certificate of Arrival in the U.S.

(2) this form was properly completed,

(3) listed job duties are in compliance with state and

[ ] Driver’s License

federal laws and regulations,

[ ] Hospital Record of Birth

(4) listed hours are in compliance with state and

Number of Hours able to

federal laws and regulations,

Work during a School

[ ] School Record

[ ] Baptismal Certificate

(5) this form was signed by student and employer,

Week

and I authorize the issuance of this work permit.

Not more than 18 Hours per

[ ] Other (describe)

week during a school week

Name of School District:

Printed Name of Issuing Officer:

Title:

Address:

City, State, ZIP:

Signature of Issuing Officer:

Issue Date:

Telephone Number:

(x)

Must Print front and back on Pink Paper

Form CA-6 (revised 2014) Combined Offer of Employment & Work Permit / Age Certificate

Instructions for completing CA-6 must be printed on back of form to be valid.

State Of Michigan Combined Offer Of Employment And Work Permit/age Certificate Ca-6 For Minors Under 16 Years Of Age

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