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Get Statement Of Intent To Employ Minor And Request For Work Permit - Galileoweb

Ity number Street address Date of birth Age City ZIP Code Home telephone City ZIP Code Grade School telephone School name Street address For Employer to Complete (Please review rules for employment of minors on reverse.) Name of business Street address City ZIP Code Business telephone Minor s work duties Hourly wage Employer s Workers Compensation Insurance Company: Maximum number of hours of employment when school is in session: Mon. Wed Tues Thurs Fri. Sat. Sun.

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