DEPARTMENT OF LIQUOR CONTROL · COUNTY OF MAUI 2145 Kaohu Street, Room 105, Wailuku, Hawaii 96793 · Phone 243-7487 or 243-7101 788 Pauoa Street, Room 102, Lahaina, Hawaii 96761 · Phone 661-9581 REGISTRATION OF MINOR FOR EMPLOYMENT WARNING: An employee 16 or 17 years of age shall NOT be permitted to work until this registration is completed, approved by the Director and a minor registration card for the specific licensed premises has been issued. Employees 16 or 17 years of age shall NOT perform any duties that are prohibited by law and in an occupation declared hazardous. EMPLOYER TO COMPLETE THIS SECTION (Please Print or Type) 1. Last name, First name, Middle name of Minor 2. Date of Birth Age Sex 3. Home Address of Minor Apt. # City & State Zip Code 4. Home Telephone Number 5. Date Employed Position 6. Signature of Minor Licensed Premises (Trade Name): Date Signature of CORPORATE OFFICER or AUTHORIZED AGENT Print Name/Title A LEGAL PARENT OR GUARDIAN MUST COMPLETE THIS SECTION AT TIME OF INTERVIEW WITH INVESTIGATOR: This request for the above named minor for employment at a liquor licensed premises is made with my knowledge and consent. Signature of Parent or Legal Guardian Print Name Business Telephone Number Home Telephone Number Page 1 of 1 American LegalNet, Inc. www.FormsWorkFlow.com DLC-023 [rev 04/12]