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Form Ol-C-41 - Intention To Employ Minors Under 18 - State Of Louisiana Workforce Commission

OL-C-41 (Rev. 08/2011)

STATE OF LOUISIANA

WORKFORCE COMMISSION

OFFICE OF REGULATORY SERVICES

To obtain a vacation work permit or employment certificate, the minor must bring this properly completed form, along with suitable proof

of age, to the parish or city school superintendent.

INTENTION TO EMPLOY

MINORS UNDER 18

The certificate or vacation work permit will be denied unless all conditions regarding hours, type of employment, etc., are in accordance

with provisions of R.S. 23:151-234.

In accordance with provisions of R.S. 23:151-234, employers who employ minors illegally are subject to civil money penalties and/or

criminal prosecution which may result in criminal fines and jail sentences.

Name of Minor _______________________________________

Name of Employer (DBA)______________________________________

Physical Address _____________________________________

Physical Address_____________________________________________

(Where work will be performed)

Age _______ Sex_______ Date of Birth___________________

Employer’s Telephone No._____________________________________

Minor will work _____ hours per day; ______ days per week;

Industry of Employer_________________________________________

Shift will begin at ______ and end at _______ prior to school days.

Job Tasks to be Performed by Minor ____________________________

(

time)

(time)

Minors ages 14 & 15 only: Shift will begin at ________ and end at _________ June 1 - Labor Day.

(time)

___________________________________________________

____________________________________________________________

Please Print Name & Title of Employer Representative

Signature of Employer Representative

=========================================================================================================

PARENT'S CONSENT STATEMENT

I, ____________________________________, _________, _______________ hereby give consent for ___________________________________

(signature of consenting parent or legal guardian)

(date)

(telephone number)

(name of child)

to be employed by the above named employer.

THIS FORM MUST BE EXECUTED AND SIGNED BY AN OFFICER OF EMPLOYING FIRM.

Form Ol-C-41 - Intention To Employ Minors Under 18 - State Of Louisiana Workforce Commission