ODRISA Permit Application

COVID-19

Yes

Is your request for a permit related to COVID-19? Check YES or NO. If you check yes, upload supporting documents as directed by emergency rule effective 3/20/20.

Company Name

The OFFICIAL name of the company.

Reference Number

If you have previously submitted an ODRISA permit application in this calendar year and were provided a reference number, please include the reference number here.

Owner/Contact

Email Address

Business Address Line 1

(Not A PO BOX)

Business Address Line 2

City

State

ZIP Code

Business Phone

Business Fax

Website

Total Number of Employees

Total number of persons employed by the company. (NUMBERS ONLY)

From (Date)

Date the permit starts.

To (Date)

Date the permit ends.

More than 8 weeks?

Select YES if this permit request encompasses more than 8 weeks OR if with this permit request you would exceed 8 weeks cumulatively with other permits you have requested in the current Calendar Year. If YES you must select one of the two options below AND upload an attachment explaining the request. If NO you are not required to select either option.

Check one or both of the following conditions if the permit request exceeds 8 weeks.

Increasing the number of employees or adjusting work schedules would not remedy the operational need for this permit.

Business and economic conditions make this request necessary.

Job Title/Classification 1

Please submit the anticipated number and title/skills of employees covered by this permit. If you require a permit for more than (4) titles/skills, please submit a second request.

Number of Employees (1)

NUMBERS ONLY

Job Title/Classification 2

Number of Employees (2)

Job Title/Classification 3

Number of Employees (3)

Job Title/Classification 4

Number of Employees (4)

This Constitutes My Electronic Signature

Signed

I [OWNER/CONTACT] certify that all employees covered by this permit are in fact voluntarily working and no action will be taken to discipline any employee who chooses not to work on their day off as permitted by the Act (820 ILCS 140/1-9). I certify that all information provided and the statements made herein are true, correct, and complete.

Attachments

If your request is for more than 8 weeks you must submit an attachment explaining your request. Multiple files can be uploaded by holding down Shift or Ctrl while selecting.