Application for Federal Certificate
U.S. Department of Labor
of Age
Employment Standards Administration
Wage and Hour Division
IMPORTANT: Complete this form carefully. Print or write plainly. No Federal Certificate of Age may be issued
OMB No. 1215-0083
unless completed application form has been received and without appropriate documentary proof of age.
Expires: 11-30-2011
(29 C.F.R. Part 570). (See instructions on reverse side.) Note: Persons are not required to respond to this
collection of information unless it displays a currently valid OMB control number.
Name (First, middle, last)
2. Sex
1.
Male
Female
3. Present address, (Number, street, P.O. Box No., City or Town, County, State, Zip Code)
5. Date of birth (Month, day, year)
4. Place of birth (City, County, State)
9. Check type of proof of age ATTACHED to this application
6. Father's full name
(See instructions on reverse side.)
Birth Certificate
Passport
7. Mother's full name (include maiden name, if any.)
Baptismal Certificate
Other (Identify)
8. Name as shown on any previous age certificate
Life insurance Policy
10. If for any reason, other than marriage, your last name as shown on this application is
11. Signature of minor submitting
not the same as that shown on the documentary proof of date of birth attached to this
application
application, please indicate when your name was changed and where this change is
recorded (i.e., court records, school records, etc.)
INTENTION TO EMPLOY PORTION
TO BE COMPLETED BY EMPLOYER IF: Applicant is under 18 years of age and to be employed in industry, or under 16 years of age
and to be employed In Agriculture.
12. Specific occupation of minor to be employed
13. Industry (Such as retail, wholesale, manufacturing, agriculture)
Name of employer (Company)
14.
15. Business address of employer (Number, Street, City, State, Zip Code)
16. Daily and weekly hours minor is to be employed
(If minor is under 16 years of age)
The undersigned intends to employ the above named minor immediately upon receipt of a certificate showing that such minor
is above the oppressive child-labor age for the occupation specified above, as defined by the Fair Labor Standards Act of 1938,
as amended, and subsequent regulations.
Signature of employer or authorized representative
Date
Form
WH-14
Rev. Oct. 2008