DESIGNEE APPLICATION FORM

Approval is hereby requested for the designation of the following person outside the staff of the Department of Social Services to issue Youth Employment Certificates in this county.
I.    Designee Information
  Name:
  Position Title:
  Agency/Institution/Organization:
  Street Address:
  Mailing Address (if different):
  Telephone Number:
II.   Supervisor Information
  Name:
  Position Title:
  Mailing Address (if different from Designee):
  Telephone Number:
  Consent of Supervisor
(by signing you agree to this designation)

  Date
III.   Reason for Designation
 
IV.   Submitted by Director of Social Services
  Name:
  Mailing Address:
  Telephone Number:
  County:
  Contact Person (if other than Director)
  Signature of Approval:   Date
V.   Mail Completed Form
  N.C. Department of Labor
Wage and Hour Bureau
1101 Mail Service Center
Raleigh, NC 27699-1101

FOR NCDOL Use Only

ID#: __________
Date Issued: __________
Date of Training:
____________