Form Ca-7 - Combined Offer Of Employment & Work Permit And Age Certificate printable pdf download

Permit Number for School Use

(optional)

State of Michigan: Combined Offer of Employment and Work Permit/Age Certificate

CA-7 for minors 16 and 17 years of age

Employer Information:

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

- The employer or an employee who is 18 years of age or older 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. ALL FIELDS MUST BE COMPLETED. Back of this form must have summary of requirements.

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

Name of Minor:

Address:

City & ZIP:

| |

Age:

Date of Birth (MM/DD/YYYY):

Last 4 Digits of Soc. Number

Contact Number:

| |

| | (

)

Name of School (present or last attended):

School Address:

City & ZIP:

| |

Last Grade Completed:

School Status (check one):

Type of Business (i.e., fast food, manufacturing):

| | ☐ in school, ☐ home school, ☐ online/cyber/virtual school, ☐ not attending school | |

☐ Parent/ ☐ Guardian Name (check one):

Signature of Minor:

Parent/Guardian Telephone:

| |

| | (

)

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

Name of Business:

Address:

City & ZIP:

| |

Earliest Start Time Not before

Latest End Time Not later

Hours per Day

Days per Week:

Total Hours of Employment:

3:00 pm (

Monday-Friday)

10:30 pm (Sunday-Thursday)

No more than 24 when school is in session

When school is in session

11:30 pm (Friday-Saturday)

No More than 8

No more than 6

No more than 48 when school is not in session

No earlier than 6:00 am (Sat-Sun) 11:30 pm school vacation

Spring/Summer/Christmas/Winter vacation

Applicants Job Title:

Hourly Wage:

Name of Job Duties/Tasks to be Performed by the Minor:

Name Equipment/Tools to be Used by Minor:

| |

Individual Application for Hours Deviation for 16 and 17 Year Old Minors along with this original yellow CA-7 must be mail to:

| MDE/OCTE P.O. Box 30712, Lansing, Michigan, 48909, for approval.

Signature of Employer:

Title:

Telephone:

Date:

| |

| | (

)

| |

Section III: Certification

Each Box must be Completed by a Michigan School’s Issuing Officer – Must be Signed by the Issuing Officer to be Valid

This is to certify that: (1) the minor personally appeared before me, (2) this form was properly completed, (3) listed job duties are in compliance with state and federal

laws and regulations, (4) listed hours are in compliance with state and federal laws and regulations, (5) this form was signed by student and employer, and I authorize

| the issuance of this work permit.

Evidence of Age confirmed by (Issuing officer checks one):

☐ Birth Certificate, ☐ Driver’s License, ☐ School Record, ☐ Certificate of Arrival in U.S., ☐ Hospital Record of Birth, ☐ Baptismal Certificate,

| ☐ Other (Describe):

Number of Work Hours per week, when School is in Session:

Number of Work Hours while school is not in session (Summer, Spring, Xmas vacation)

No more than 24 per week

No More than 48 per week

Name of School District:

Address:

City, State, and ZIP:

Telephone: