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State of Michigan

Permit Number for School Use

Combined Offer of Employment and Work Permit/Age Certificate

(optional)

CA-7 for minors 16 and 17 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 an ink pen. ALL FIELDS MUST BE COMPLETED. See back of this form for summary of requirements.

Section I: To be Completed by Minor Applicant and Parent/Guardian

Name of Minor:

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:

Last Grade Completed:

School Status (check one):

[

] in school

[

] left school

[

] home schooled

Signature of Minor:

Name of Parent/Guardian (circle one):

Parent/Guardian Telephone:

(x)

Section II: To be Completed by the Employer - Offer of Employment

Name of Business:

Address:

City:

ZIP:

Earliest Starting Time a.m./p.m.:

Latest Ending Time a.m./p.m.:

Hours per Day:

Number of Days per Week:

Total Hours of Employment per

Week:

Applicant’s Job Title:

Hourly Wage:

Job Duties/Tasks to be Performed by Minor:

Equipment/Tools to be Used by Minor:

Will the minor be working under an existing hours deviation granted by the Michigan Department of Education?

[ ] No

[ ] Yes

If yes, attach a copy of the approved Michigan hours deviation and retain parent/guardian consent at the work site.

Signature of Employer:

Title:

Telephone:

Date:

(x)

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

A student 16 or 17 years of

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

age may work when

SCHOOL IS IN SESSION:

This is to certify that:

No more than 24

[ ] Certificate of Arrival in the

(1) the minor personally appeared before me,

[ ] Birth Certificate

U.S.

hours per week

(2) this form was properly completed,

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

A student 16 or 17 years of

federal laws and regulations,

age may work when

[ ] Driver’s License

[ ] Hospital Record of Birth

(4) listed hours are in compliance with state and

SCHOOL IS NOT IN

federal laws and regulations,

SESSION :

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

No more than 48

[ ] School Record

[ ] Baptismal Certificate

and I authorize the issuance of this work permit.

hours per week

[ ] Other (describe)

Name of School District:

Printed Name of Issuing Officer:

Title:

Address:

City, State, ZIP:

Signature of Issuing Officer:

Issue Date:

Telephone Number:

(x)

Form CA-7 (revised 10/18/2011) Combined Offer of Employment & Work Permit and Age Certificate

Must Print on Yellow Paper.

Instructions for completing CA-7 must be printed on back of form for form to be valid.

Form Ca-7 - Combined Offer Of Employment And Work Permit/age Certificate Ca-7 For Minors 16 And 17 Years Of Age

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