Certificate Of Employment Page 2
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HAWAII DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS
WAGE STANDARDS DIVISION - CHILD LABOR OFFICE
CERTIFICATE OF EMPLOYMENT
CL-1 APPLICATION FOR MINOR'S
(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
1. Last Name of Minor, First Name, Middle Initial
Male
2.
3. Age
Information
Female
4. Last four digits of minor's Social Security No. xxx - xx - _________
5. Home Phone (
)
Zip Code
6. Mailing Address of Minor
Apt
City
Yes
7. Name of School Attending
Year-round:
No
Employer
8a.
9.
Employment to Begin On
Job Title
8. Job Minor Hired For
to Complete
10. Hours of Work (See instruction for restrictions):
c. # Minutes
b. End Time
d. # Hours/Day
a. Start Time
e. # Days/Week
Break
Monday - Friday
Saturday
Sunday
Employer
11. Name of Business
Information
12. Business Address (Mailing Address if not same)
City
Zip Code
14a. Business Phone
14b. Business Fax
13. Employer DOL Number
(
)
(
)
___ ___ ___ ___ ___ ___ ___ ___ ___ ___
15. Type of Business
16. Signature of Employer/Representative
Title
Print or Type Name of Employer/Representative
17. Date of Application
This request for an employment certificate is made with my knowledge and consent:
Parent or
Signature
18. Print Name of Parent or Guardian
guardian
to complete
Phone
Address
(
)
Date of Birth
FOR CHILD
Proof of Age: BC
SR
SID
Other
HDL
I
MID
LABOR
CL-1 Ref No.
DLIR Official Date TA Issued
OFFICE
USE ONLY
(Rev. 12/12)
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