Employer'S Request For Child Labor

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STATE OF NEW HAMPSHIRE
DEPARTMENT OF LABOR
PO BOX 2076
CONCORD, NH 03302-2076
EMPLOYER’S REQUEST FOR CHILD LABOR
Please issue a NH Youth Employment Certificate to:
______________________________________________________________________________
NAME OF MINOR
SOC. SEC. NUMBER (optional)
______________________________________________________________________________
AGE
DATE OF BIRTH
SEX
That he/she may be legally employed, in accordance with Revised Statutes Annotated 276-A as
amended, by
______________________________________________________________________________
(SHOW CORPORATION OR TRADE NAME, IF ANY)
(FED. ID #)
______________________________________________________________________________
STREET & NUMBER
CITY, STATE, ZIP
TEL. #
______________________________________________________________________________
INDUSTRY OF EMPLOYER
______________________________________________________________________________
NATURE OF EMPLOYMENT – BE SPECIFIC
With this application the minor must present a Birth Certificate or other evidence of date of birth,
to the School Department, and the certificate will be issued there. The certificate must be kept on
file for your records.
_________________________________
Employer’s Signature/Telephone Number

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