New Jersey Department Of Education Employment Certificate Form - Free Download
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New Jersey Department Of Education Employment Certificate Form
New Jersey Department Of Education Employment Certificate Form
A300 Combined Certification Form Date(s) of previously issued certificates (if applicable): ________________
A. Minor’s Personal Information
First Name M.I. Last Name
Social Security No.
Street Address (Line 1) Floor/Apt. No. (Line 2)
Date of Birth Age City of Birth
City State Zip Code
County of Birth State/Country of Birth
Telephone No. Cell/Alternate No.
Male Height __________ Hair Color ______________
Female Weight __________ Eye Color ______________
Parent/Guardian First Name Parent/Guardian Last Name
Distinguishing Facial Marks (if applicable)
Parent/Guardian Address (if different than minor’s address) Floor/Apt. No. (Line 2)
I hereby authorize the employment of my child as specified below under
Employment Information.
__________________________________________________________
Signature of Parent/Guardian Date
City State Zip Code
Parent/Guardian Telephone No. Alternate Telephone No.
B. Employment Information
Employer Business Name
Type of Business/Industry
Street Address (where minor will be employed) Floor/Suite (Line 2)
Minor’s Job Title (Be specific)
City State Zip Code
Is liquor sold on the premises Yes No
If Yes, are the entire premises licensed Yes No
If No, describe what areas of the premises are licensed, including any
outside grounds:
__________________________________________________________
Contact Person Name
Telephone No. Alternate Telephone No.
Promise of Employment: I have offered employment to the above
named minor for the hours stated. I understand that these hours may be
flexible but may not exceed the number of hours permitted by law
according to the age of the minor.
__________________________________________________________
Signature of Employer Date
C. Physician’s Certification (to be completed by licensed physician): I hereby certify that I have examined the above named minor on __________________
and I designate the minor’s physical qualifications regarding the above promise of employment as: (Date)
Physically Qualified Physically Qualified with the following limitations ________________________________________________________________
_____________________________________________________________________________________________________________________________________
Signature of Doctor Date Address
D. 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):
Birth Certificate Baptismal Certificate Passport Other documentary proof in existence for at least one year (specify): __________________
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 birth
E. School Record (to be completed by school that the minor attends) F. Issuing Officer Certification
School District County
School District County
Name of School
School District Address
School Address
Telephone No.
Last Grade Completed __________
Regular Employment Certificate
Vacation Employment Certificate (summer & other school vacations)
Age Certificate (issued to persons 18 to 21 years of age) Age: _______
The above named minor attends school in this district and has completed the work
of the above grade. To the best of my knowledge the minor can do the work
pr
oposed without impairment of progress in school.
_________________________________________________________________
Signature of Principal Date
__
______________________________________________________________
Signature of Minor Date
________________________________________________________________
Signature of Issuing Officer Date of Issue Certificate No.
Cooperative Education Experience (CEE) - Hazardous Occupation CEE - Non-Hazardous Occupation Paid Structured Learning Experience
NEW JERSEY DEPARTMENT OF EDUCATION Date Printed: _____________
Minor’s Hours of Work (Provide daily hours and/or start and end times)
_______________ ______________ ______________ ______________ ______________
Mon Tues Wed Thurs Fri
Sat ______________ Sun ______________ Total Hours for Week:___________
Wages: Per Hour ____________ Weekly ____________ Other__________________
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A300 (R-9-2012) New Jersey Department of Education
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