Application For A Minor'S Employment Certificate Template - Government Of Guam, Department Of Labor

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GOVERNMENT OF GUAM, DEPARTMENT OF LABOR
Clear Form
WAGE AND HOUR DIVISION
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Mailing Address: P.O. Box 9970, Tamuning, Guam 96931
Location: 1
Floor, Hakubotan BuildingE.T. Calvo Parkway Memorial, Tamuning, Guam 96911
st
APPLICATION FOR A MINOR’S EMPLOYMENT CERTIFICATE
(Only applicable for minors below the age of 16 years)
INSTRUCTIONS
: A minor must personally return the completed application form, accompanied with
birth certificate, U.S. Passport, Baptismal Certificate
Guam ID,
a COPY of a
,
OR any bona fide
documentation indicating age and date of birth. Upon approval of this application, a Certificate to
Employ Minor will be issued within 5 working days. Original application must be personally submitted
to our office, by the applicant.
Facsimile transmittal, e-mailing, or mailing of application is not
acceptable.
I. TO BE COMPLETED BY APPLICANT
Full Name (Last, First, M.I.)_____________________________________________
Age:_________ Gender:___________ Social Security No./I.D.:_________________
Mailing Address:________________________________________________________
Home Address:_________________________________________________________
___________________________________
__________________
SIGNATURE
DATE
This request for an employment certificate is made with my knowledge and consent.
____________________________________
__________________
SIGNATURE OF PARENT/GUARDIAN
DATE
___________________________________
PRINT NAME OF PARENT/GUARDIAN
II. TO BE COMPLETED BY THE EMPLOYER
:
Name of Establishment/Employer:____________________________________________
Type of business:______________________ Business Location:____________________
Mailing Address:__________________________________________________________
Telephone Nos.:_____________________________ Fax No.:______________________
Applicant’s occupation:_______________________________Rate of Pay:___________
Hours of Work: (From)___________ (To)___________ Meal Period:________________
Total Hours per day:____Total Days Per week:_____ Date of employment:___________
This is to certify that the employment of the above minor will be in full compliance with the
Child Labor Laws, Rules and Regulations.
Employer’s authorized signature _____________________________________________
Print Name:________________________________Job Title:______________________
FOR WAGE AND HOUR OFFICE ONLY:
Document submitted for verification of date of birth (indicate type & No.)_______________
_____________________________________Date of Birth:__________________________
Place of Birth:_______________________________________________________________
Verified & Recommended by:____________Employment Certificate No.:_______________
Comments:__________________________________________________________________

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