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INFORMATION SECTIONS: All signatures indicating approval must be affixed INFORMATION SECTIONS: All signatures indicating approval must be affixed. Please print or type

SCHOOL CONDUCTING PROGRAM

Name:______________________________________________________________________________

Address:____________________________________________________________________________

_________________________________________________________
(Teacher/coordinators signature)

Type of Program:_____________________________# of minutes of Related Instruction Weekly:_____

_________________________________________________________
(Co-op coordinators signature, if applicable)
------------------------------------------------------------------------------------------------------------------------------
STUDENT-LEARNER SECTION

Name:_________________________________________________________________________________

_________________________________________________________
(Student-Learners signature)

Address:_______________________________________________________________________________

Telephone #:______________________________Grade Level:_______ Date of Birth:_______________

Occupational Objective: _______________________________SS #:_____________________________

# Hours in School Daily: _____________________# Hours Employment Daily:_____________________

_____________________________________________________________
(Parents of Guardians signature)
------------------------------------------------------------------------------------------------------------------------------


Name of Establishment:____________________________________________ Fed. ID#_______________

Address:_____________________________________________________________________________

Kind of Business:_______________ # of employees ________________Telephone:________________

Beginning Date of Employment:_______________ Anticipated Date of Ending Employment:__________

Starting Hourly Rate of Pay:_____________________ Potential Hourly Rate of Pay: _________________

As the employer, I am:






Yes No



subject to the provisions of the Fair Labors Standards Act

subject to the provisions of the State of NH Minimum Wage law

covered under the provisions of the Workers Compensation Act
subject to the Unemployment Compensation Act

________________________________________
___________________________________
(On-the-job
supervisors
signature)
(Employers
signature)
---------------------------------------------------------------------------------------------------------------------------------
TOPICAL OUTLLINE of on-the-job operations the
MACHINE TO BE OPERATED, or hazardous
Student will experience:_______________________
occupation:____________________________

___________________________________________
______________________________________
IF HAZARDOUS, ATTACH SHEET OF EXPLANATION OF WORK AND EQUIPMENT USED.

HAZARDOUS WORK IS INCIDENTAL TO TRAINING; INTERMITTENT AND FOR SHORT
PERIODS OF TIME.