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NAME OF MINOR:
PERMISSION FOR EMPLOYMENT
(In accordance with Sections §40.1-84 & §40.1-92 Code of Virginia)
I consent to my child’s employment as indicated below:
COMMONWEALTH OF VIRGINIA
TO BE EMPLOYED AT:
PHYSICAL ADDRESS OF THE EMPLOYER:
PARENT/GUARDIAN/CUSTODIAN NAME
PHONE #:
WORK/CELL #:
COMMONWEALTH OF VIRGINIA
DEPARTMENT OF LABOR AND INDUSTRY
1570 EAST PARHAM ROAD
RICHMOND, VIRGINIA 23228
City/County of
(Date) (Name of Parent)
(Notary)
Commission Expires:
Appeared before me and signed the Permission for Employment Form on
DATE OF BIRTH:
EMAIL:
PARENT/GUARDIAN/CUSTODIAN
(Parent/Guardian/Custodian Signature)
(SIGN ONLY IN THE PRESENCE OF NOTARY)
Date
(THIS FORM MUST BE NOTARIZED)
First Last MI
Sex: F M (
Circle One)
NAME OF SCHOOL ATTENDING:
(Post Office Boxes Not Accepted)
Date
Date
Day Month Year
ADDRESS:
Street City State Zip
ADDRESS:
Street City State Zip
ADDRESS:
Street City State Zip