BUREAU OF LABOR AND INDUSTRIES
Wage and Hour Division
ANNUAL EMPLOYMENT CERTIFICATE APPLICATION
for minors 14 through 17 years of age
Business Name _____________________________________________ Telephone (_____) ___________Ext.
Corporation Name (if any)
Type of Business____________________________________________ NAIC Code (if known) __________________
Site Address
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(Street) |
(City) |
(State) |
(Zip) |
(County) |
Mailing Address |
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(Street/P.O. Box Number) |
(City) |
(State) |
(Zip) |
(County) |
1.ESTIMATE the number of minors to be employed in the next twelve (12) month period:
2.Do you anticipate employing 14-15 year olds? Yes ______ No ______ 16-17 year olds? Yes ______ No
3.Describe the duties of the minors to be employed, the work areas, and the address(es) where the work is to be performed, if other than the above site. Please attach a list of locations if necessary.
4.List all power-driven machinery/equipment minors will operate or assist in the operation of:
5. Do you anticipate employing minors in agriculture? |
Yes _____ |
No _____ |
Operation of or riding in or on a tractor? |
Yes _____ |
No _____ |
Operation of or riding in or on other farm machinery? |
Yes _____ |
No _____ |
I certify that the information contained in this application is true and that I have received a summary of the child labor laws. I agree to:
1)Employ minors consistent with the application herein;
2)Comply with child labor laws; and
3)Report any changes in the above information by filing a Notice of Change (To Annual Employment Certificate) form between renewal periods within 15 days of the change.
_________________________________________________________________________ Date
(Signature of Employer or Representative)
______________________________________________ Telephone No. (_____)_________________ Ext.
(Printed Name of Employer or Representative)
RETURN THIS APPLICATION TO:
Bureau of Labor and Industries
Child Labor Unit - Suite 1045
800 NE Oregon Street
Portland, OR 97232-2180
Telephone: (971) 673-0836
Fax: (971) 673-0769