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 Age Certificate (issued to persons 18 to 21 years of age) The above named minor attends school in this district and has completed the work

 Vacation Employment Certificate (summer & other school vacations) School Record (to be completed by school that the minor attends)  Affidavit of Parent/Guardian together with 1) physician’s statement of opinion as to age of minor, and 2) school record of age and the above date of birthĮ. Other documentary proof in existence for at least one year (specify): _ Proof of Age (for Issuing Officer): I have examined the proof of age submitted by the above named minor which was in the form of (select one):  Physically Qualified with the following limitations _ĭ. Physician’s Certification (to be completed by licensed physician): I hereby certify that I have examined the above named minor on _Īnd I designate the minor’s physical qualifications regarding the above promise of employment as: _ _ _ _ _įlexible but may not exceed the number of hours permitted by lawĬ. Promise of Employment: I have offered employment to the above Minor’s Hours of Work (Provide daily hours and/or start and end times) If No, describe what areas of the premises are licensed, including any If Yes, are the entire premises licensed? Street Address (where minor will be employed) I hereby authorize the employment of my child as specified below under Parent/Guardian Address (if different than minor’s address)

Landlord (Tenant) Recommendation Letterĭate(s) of previously issued certificates (if applicable): _Ĭooperative Education Experience (CEE) - Hazardous Occupationĭistinguishing Facial Marks (if applicable).