Application for Federal Certificate of Age U.S. Department of Labor 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. 1. Name (First, middle, last) 2. Sex 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 (See instructions on reverse side.) 6. Father's full name 8. Name as shown on any previous age certificate Birth Certificate Passport Baptismal Certificate 7. Mother's full name (include maiden name, if any.) Other (Identify) Life insurance Policy 10. If for any reason, other than marriage, your last name as shown on this application is not the same as that shown on the documentary proof of date of birth attached to this application, please indicate when your name was changed and where this change is recorded (i.e., court records, school records, etc.) 11. Signature of minor submitting application 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) 14. Name of employer (Company) 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 American LegalNet, Inc. www.FormsWorkflow.com INSTRUCTIONS A Federal Certificate of Age cannot be issued without appropriate documentary proof of age. The proof of age that you submit will be returned to you. 1. Attach your birth certificate to this form. If you do not have a birth certificate you may: a. Obtain one from the Bureau of Vital Statistics in the State where you were born, b. Or (if unable to obtain a birth certificate) attach a copy of an official document which shows your full name, date (month/day/year) and place of birth, and parents' names, such as: - A baptismal certificate, - A bonafide contemporary record of births in the Family Bible, - A life insurance policy at least one year old, - A passport, or certificate of arrival in the U.S. at least one year old, - A school record of age with sworn parental statement and physician's certificate of physical age. 2. Return the completed form with the documentary proof of age to the address shown at the top of this form. If the information that you give is complete, the documentary proof of age is satisfactory and the job you are to do is permissible for a person of your age, the certificate will be issued and given to the employer except for those minors who are employed in agriculture or are 18 years of age or older when the certificate may be given to the minor. Public Burden Statement This report is authorized by section 3(l) of the Fair Labor Standards Act (FLSA). 29 U.S.C. § 203(l). Your response is required to obtain or retain a benefit. 29 C.F.R. § 570.5. The Department of Labor uses the information provided on this application, along with other documentary evidence of age, in determining whether to issue a Federal Certificate of Age. While the Department of Labor makes no assurances of confidentiality to information provided in response to this request, any such disclosure would be in accordance with the provisions of the Freedom of Information Act, 5 U.S.C § 552; the Privacy Act, 5 U.S.C. § 552a; and their respective regulations, 29 C.F.R. Parts 70, 71. We estimate that it will take an average of 10 minutes to complete this collection of information, including time for reviewing instructions, searching existing data sources, gathering and maintaining the records needed, and completing and reviewing the collection of information. Send comments regarding these estimates or any other aspect of this collection of information, including suggestions for reducing burden, to the Administrator, U.S. Department of Labor, Room S-3502, 200 Constitution Avenue, N.W., Washington, D.C. 20210. DO NOT SEND THE COMPLETED FORM TO THIS OFFICE American LegalNet, Inc. www.FormsWorkflow.com