Work Permit Form - Alaska Department Of Labor And Workforce Development printable pdf download

ALASKA DEPARTMENT OF LABOR & WORKFORCE DEVELOPMENT

INDIVIDUAL WORK PERMIT APPROVED

GENERAL DUTIES WORK PERMIT

APPROVED AS AMENDED

APPROVED FOR:

____________________________________

16 & 17 YEAR OLDS; OR

14 - 17 YEAR OLDS

____________________________________

By: ________________________________________

DENIED

Date: ____________________

By: _______________________________________

GENERAL DUTIES WORK PERMIT:

1. Employer completes and signs Section A.

Date:

2. Employer submits work permit to Wage and Hour office

INDIVIDUAL WORK PERMIT:

3. The approved duties are returned to the employer. After

1. Employer completes and signs Section A

employer obtains the signature of the minor’s parent or

2. Parent or guardian completes and signs Section B.

guardian in Section B, the minor may begin work.

3. Employer submits work permit and LEGIBLE copy

4. Employer must return a copy of the work permit signed

of minor’s proof of age to the Wage and Hour office.

by the parent or legal guardian and LEGIBLE copy of

4. When the approved work permit is returned,

proof of age to the Wage and Hour office within seven

the minor may begin work.

(7) calendar days of minor beginning work.

Section (A) to be completed by EMPLOYER

Name of Employer:

Employer Fax Number:

DBA/

Employer Phone Number:

Employer's Local Mailing Address:

City

Zip

Location of Employment (Physical Address):

City

Zip

Duties to be performed by minor:

Tools, Equipment or Machinery to be Used by Minor:

Do these duties involve being on a licensed restaurant designated premise where alcoholic

Hourly Rate:

Pay Periods:

beverages are served?

Yes

√ SEE REVERSE SIDE - FEDERAL LIMITATIONS MAY BE MORE STRICT.

HOURS OF WORK FOR YOUTHS AGES 14 AND 15 YEARS WILL BE RESTRICTED AS INDICATED BELOW.

When school is in session, hours will be limited to a combined total of nine hours of school attendance plus employment in any one day; work will be performed only

between the hours of 5 a.m. and 9 p.m.: total hours worked in one week will be limited to 23 hours.

During school vacations, work hours will be limited to a maximum of 8 hours per day and a maximum of 40 hours per week and work will be performed only between

the hours of 5 a.m. and 9 p.m.

Alaska law (AS 23.10.350 (c)) states that a minor under 18 years of age:

(i)

may not be employed or allowed to work more than six days a week

(ii) who works for five (5) consecutive hours without a break is to have a break of at least 30 consecutive minutes before continuing work

I affirm and agree that such working conditions will be maintained and that all changes shall have the prior approval of the

Commissioner of Labor & Workforce Development.

_____________________________________________________________________________________________________________________

____________________________________________________________________

______________________________________

Printed Name of Employer or Agent Acting for Employer

Signature

Date

Section (B) to be completed by PARENT or GUARDIAN prior to employment of minor

PROOF OF CHILD'S AGE: YOU MUST PROVIDE ONE OF THE FOLLOWING DOCUMENTS OR A COPY THEREOF

Driver's License or Permit,

State I. D.,

Birth Certificate,

Passport,

Authenticated School Records,

Military I. D.,

Baptismal Certificate

An official signed statement of B.I.A. census records

Other (Specify) _______________________________________________________________________________________________________________

Name of Minor (Print):

Address:

Date of Birth:

I affirm that I am the parent/stepparent

or the legal guardian

of the above-named minor and that such minor has my consent to be employed in any

occupation authorized by the Alaska child labor laws, Alaska Statutes 23.10.325-370.

_________________________________________________________________________________________________________________________________________________

______________________________________

____________________________________

Signature (Legal guardian must attach documentation)

Telephone Number

Date

NOTICE:

All information requested is required to process this work permit.

Records of the Department are public records and may be subject

to inspection and copying under AS 09.25.110-220 or be provided to other State agencies (see AS 44.99.310).

MAY2005 WPFRONT Indv-Gnrl

Work Permit Form - Alaska Department Of Labor And Workforce Development

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