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Youth Employment Standards Individual Hours Deviation Application

Business Name

Corporation Name

Legal ID

Address

City

State

Zip Code

Telephone Number

Business Email

Website

Type of Business

Workers’ Compensation Insurer

Policy Number

Detailed duties to be performed by minor

Location where minor will work the deviated hours if approved by the Department

City

State

Zip Code

Minor's Name

Last 4 Digits of Social Security Number

Date of Birth (If Known)

During the period school is in session, the business listed above requests approval to employ the named employee as follows Monday through Friday a shift beginning when the minor is not required to attend school. Monday through Thursday no later than 12:00 a.m., Friday a shift ending no later than 2:00 a.m. Saturday. Saturday a shift beginning no earlier than 5:00 a.m., or a shift ending no later than 2:00 a.m. Sunday. Sunday a shift beginning no earlier than 5:00 a.m., or a shift ending no later than 12:00 a.m. Monday.

When school is not regularly in session, Spring, Summer, Winter, Christmas break/vacation period, the business listed above requests approval to employ the named employee during the following hours A shift beginning no earlier than 5:00 a.m. and a shift ending no later than 2:00 a.m.