Application For Employment Of A Minor

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Mail To:

Arkansas Dept of Labor

Labor Standards Section

Arkansas Department of Labor

10421 West Markham

APPLICATION FOR EMPLOYMENT OF A

Little Rock, Arkansas 72205-2190

Ph 501-682-4500 fax 501-682-4506

MINOR

TDD (800) 285-1131

INSTRUCTIONS

SECTION 1

INSTRUCTIONS:

1. All sections must be completed before submitting the application. If all sections are not completed, the application will be denied.

2. As a means of establishing age, please submit a copy of one of the following documents with the application:

a) Certificate of Birth; b) Driver’s License; c) State or Federal I.D. card d) notarized copy of school record listing the minor’s name and date

of birth

3. The parent/guardian/custodian, child and the employer must sign the application or the application will be denied.

NOTE: A WORK PERMIT IS NOT REQUIRED FOR A MINOR 16 YEARS OF AGE. HOWEVER THERE ARE FEDERAL LAWS THAT LIMIT THE

JOBS THESE MINORS CAN PERFORM. FOR MORE INFORMATION PLEASE VISIT

SECTION 2

Statement of Parent, Guardian Or Custodian

I, the undersigned, hereby affirm that I am the __________________________of___________________________________________ now residing at

(Parent, Guardian or Custodian)

(First Name)(Middle Name)(Last Name)

________________________________________,___________________________,___________________,_________________,______________

(Street and Number)

(City)

(County)

(State)

(Zip Code)

and that _____________was born in ________________________,__________________________,________________ on the _____________ day of

)

(He/She)

(City)

(County)

(State

_______________________,

___________ and is now ____________years of age. School currently attending or last attended:

(Month)

(Year)

______________________________________________________ , _______________________________________________________

(Name Of School)

(Location)

I am willing that ________be so employed as stated in Section 3 of the application and ask that an employment certificate be issued as provided by law.

(He/She)

_____________________________________

_________________________________________ ________________________________________

(Signature of Parent/Guardian/Custodian)

(Printed Name of Parent/Guardian/Custodian)

(Signature of Minor)

SECTION 3

Intention to Employ

This section is to be completed in full and signed by the employer. Information must be provided or permit will not be issued

The undersigned intends to employ:

________________________,______________________________,_________________,_______________

in the capacity of

Name of Minor

Address

City

State

________________________in the_______________________ industry for __________days per week ,________hours per day on the following days:

Occupation

Type of business

(Complete start and end times for only the days that apply)

Mon: Start_________ End___________ Tues: Start___________ End___________ Weds: Start___________ End___________ Thurs: Star t__________ End__________

Fri: Start__________ End___________ Saturday: Start__________ End____________ Sunday: Start__________ End____________

Employment during Vacation Periods?

Yes

Employment during school year

Yes

If the minor’s schedule will vary, list the earliest possible beginning time and the latest possible ending time. Please note that Arkansas law allows a minor

14 and 15 years of age to work until 7:00 p.m. on nights that precede a school day and until 9:00 p.m. on nights that do not precede a school day. If your

business is subject to the Fair Labor Standards Act, a minor may not be employed: 1) during school hours; 2) before 7:00 a.m. or after

7:00p.m., except June 1 through Labor Day, when the hour is extended to 9:00 p.m.; more than three (3) hours a day on a school day, including

Fridays; 4) more than eight (8) hours a day on a non-school day; 5) more than eighteen (18) hours a week during a school week; 6) more than

forty (40) hours a week during non-school weeks. To obtain additional information on Federal child labor laws, you will need to contact the U.S,

department of Labor at (501) 223-9114, or visit

. Failure to comply with these regulations will result in the application being

denied.

The undersigned intends to employ the above mentioned minor immediately upon receipt of a certificate issued by the Arkansas Department of Labor and

agrees to comply with the provisions of the Arkansas Statutes and the Fair Labor Standards Act relating to the employment of minors.

_________________________________________________, __________________________, ____________________, __________________,________________

Name of Business/Employer

Mailing Address

City

State

Zip

_________________________________________________________ _________________________________________________ _______________________________________________

Signature of Employer or Authorized Agent

Printed name of Employer or Authorized Agent

Employers Telephone Number (Area Code First)

REMINDER: Proof of age must be attached to application or permit will not be issued.

Office Use:

Approved ____________Denied ____________Date_____________

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