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Visit our Website at http://labor.hawaii.gov for ALL interactive and downloadable forms.
(Rev. 12/12)
HAWAII DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS
WAGE STANDARDS DIVISION - CHILD LABOR OFFICE
CL-1 APPLICATION FOR MINOR'S CERTIFICATE OF EMPLOYMENT
(To be Used for Minors Under 16 Only)
WARNING: A minor is NOT permitted to work until the employer receives a Temporary Authorization slip.
The original signed application must be completed and returned to the Child Labor Office and when approved, the employer will be
issued a temporary authorization slip and the minor's Certificate of Employment.
See additional information on the instruction
sheet.
PRINT OR TYPE - MUST BE LEGIBLE: (Use black ink)
Minor's
Information
1. Last Name of Minor, First Name, Middle Initial
3.
Age
2.
Male
Female
5.
Home Phone
( )
6. Mailing Address of Minor
Apt City
Zip Code
7. Name of School Attending
Year-round:
Yes
No
Employer
to Complete
8. Job Minor Hired For
9. Employment to Begin On
10. Hours of Work (See instruction for restrictions):
a. Start Time
b. End Time
c. # Minutes
Break
d. # Hours/Day
e. # Days/Week
Monday - Friday
Saturday
Sunday
Employer
Information
11. Name of Business
12. Business Address (Mailing Address if not same) City Zip Code
13. Employer DOL Number
___ ___ ___ ___ ___ ___ ___ ___ ___ ___
14a. Business Phone
14b. Business Fax
( )
( )
15. Type of Business
16. Signature of Employer/Representative Title
Print or Type Name of Employer/Representative
17. Date of Application
Parent or
guardian
to complete
( )
Phone
Address
Signature
18. Print Name of Parent or Guardian
This request for an employment certificate is made with my knowledge and consent:
FOR CHILD
LABOR
OFFICE
USE ONLY
Proof of Age:
BC
HDL
I
MID
SR
Date of Birth
Other
DLIR Official Date TA Issued
CL-1 Ref No.
4. Last four digits of minor's Social Security No. xxx - xx - _________
SID
Job Title
8a.
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source: labor.hawaii.gov
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