Employer Intent To Employ - Free Download
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Employer Intent To Employ
Employer Intent To Employ
EMPLOYER INTENT TO EMPLOY
Co./Corporate Name
Child’s Date of Birth
Type of Business
Job Description
(Include specific duties)
Trading As Name: (If different)
Lifeguard - Age15 years old Y/N: Lifeguard Certificate: Y/N
Site Address: (Location where child will work, if different)
Street
Phone Number
Suite #
City State
Zip
Company Mailing Address:
Street
Phone Number
Suite #
City
State
Zip
Email
Age 16 - 17 Age 14 - 15
Email
Phone
Number of employees at this location
Adult
Hiring Agent First Name
Last Name
(Attach copies of the certificate)
* § 40.1.94. P
roof of Age
The employer shall procure and keep on file, accessible to the Department or authorized persons charged with the enforcement
of this chapter, the proof of age as provided in § 40.1.94.
(1) A birth certificate or attested transcript isued by a registrar of vital statistics or other officer charged with the duty of recording births
(2) A baptismal record or duly certified transcript thereof showing the date of birth and place of baptism of the child
(3) Government issued ID (Passport, DMV)
* Proof of Age
Email
THIS IS NOT AN EMPLOYMENT CERTIFICATE
COMMONWEALTH OF VIRGINIA
DEPARTMENT OF LABOR AND INDUSTRY
1570 EAST PARHAM ROAD
RICHMOND, VIRGINIA 23228
Please Print Clearly
(In accordance with Sections §40.1-84 & §40.1-93, Code of Virginia)
Child’s Name
First Last MI
Sex: F M (
Circle One)
City
State
Zip
Child’s Address
Permissable Hours of work as legally allowed under
§40.1-81.1.
Day Month Year
Employer Intent To Employ Previous Page
source: doli.virginia.gov
Employer Intent To Employ
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