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NEW JERSEY DEPARTMENT OF EDUCATION

A300 Combined Certification Form

Date Printed: _____________

Date(s) of previously issued certificates(if applicable): ________________

Cooperative Education Experience (CEE) - Hazardous Occupation	CEE - Non-Hazardous Occupation	Paid Structured Learning Experience

A. Minor’s Personal Information
	
First Name	M.I.	Last Name
	Social Security No.
	
Street Address (Line 1)	Floor/Apt. No. (Line 2)
	Date of Birth	Age	City of Birth
	
City	State	Zip Code
	County of Birth	State/Country of Birth
	
Telephone No.	Cell/Alternate No.
	Male              Height __________       Hair Color ______________ Female          Weight __________       Eye Color ______________
	
Parent/Guardian First Name	Parent/Guardian Last Name
	Distinguishing Facial Marks (if applicable)
	
Parent/Guardian Address (if different than minor’s address)	Floor/Apt. No. (Line 2)
	
I hereby authorize the employment of my child as specified below under Employment Information.

__________________________________________________________ Signature of Parent/Guardian	Date
	
City	State	Zip Code
		
Parent/Guardian Telephone No.	Alternate Telephone No.
		
B. Employment Information
	
Employer Business Name
	Type of Business/Industry
	
Street Address (where minor will be employed)	Floor/Suite (Line 2)
	Minor’s Job Title (Be specific)
	
City	State	Zip Code
	Is liquor sold on the premises?                   Yes       No If Yes, are the entire premises licensed? Yes       No
If No, describe what areas of the premises are licensed, including any outside grounds:

__________________________________________________________
	
Contact Person Name
		
Telephone No.	Alternate Telephone No.
		
Minor’s Hours of Work (Provide daily hours and/or start and end times)

_______________ ______________ ______________ ______________ ______________ Mon	Tues	Wed	Thurs	Fri
Sat ______________	Sun ______________	Total Hours for Week:___________

Wages: Per Hour ____________	Weekly ____________	Other__________________
	Promise of Employment: I have offered employment to the above named minor for the hours stated. I understand that these hours may be flexible but may not exceed the number of hours permitted by law according to the age of the minor.

__________________________________________________________ Signature of Employer	Date
	
C. Physician’s Certification(to be completed by licensed physician): I hereby certify that I have examined the above named minor on __________________ and I designate the minor’s physical qualifications regarding the above promise of employment as:	(Date) Physically Qualified	Physically Qualified with the following limitations ________________________________________________________________

_____________________________________________________________________________________________________________________________________ Signature of Doctor	Date	Address
	
D. Proof of Age (for Issuing Officer): I have examined the proof of age submitted by the above named minor which was in the form of(select one):
Birth Certificate     Baptismal Certificate     Passport	Other documentary proof in existence for at least one year(specify): __________________ Affidavit of Parent/Guardian together with 1) physician’s statement of opinion as to age of minor, and 2) school record of age and the above date of birth
	
E. School Record (to be completed by school that the minor attends)
	F. Issuing Officer Certification
	
School District	County
	School District	County
	
Name of School
	School District Address
	
School Address
	Telephone No.

Last Grade Completed __________
	Regular Employment Certificate
Vacation Employment Certificate (summer & other school vacations) Age Certificate (issued to persons 18 to 21 years of age)     Age: _______

The above named minor attends school in this district and has completed the work of the above grade. To the best of my knowledge the minor can do the work proposed without impairment of progress in school.

_________________________________________________________________ Signature of Principal	Date

________________________________________________________________ Signature of Minor	Date

________________________________________________________________ Signature of Issuing Officer                         Date of Issue          Certificate No.

A300 (R-9-2012) New Jersey Department of Education

INSTRUCTIONS FOR A300 COMBINED CERTIFICATION FORM

1.	Employment Information (section B) – After you have completed your personal information (section A), bring your certification form to the employer. The employer completes the Employment Information and signs and dates the Promise of Employment. If any of the employment details have been pre-filled and are incorrect, the employer must cross out the incorrect information and enter, initial and date the corrections.

2.	 Physician’s Certification (section C) – The school district is responsible for performing the physical examination at no cost to you or your parents. A school physical (including a sports physical) performed during freshman year is good for all four years of high school (unless the school district policy specifies more frequent physicals).

If your parent/guardian prefers that you be examined by a doctor other than the one employed by the school district, you may do so at your parent/guardian’s expense. A minor is not required to obtain a physical if the parent/guardian objects (in writing) based on their religious beliefs and practices.

3.	 Proof of Age (section D) – If the school does not have a copy on file, you may be asked to provide a birth certificate, passport, baptismal certificate or other identification documentation to the School Issuing Officer.

4.	 Parent/Guardian Authorization (section A) – Your parent/guardian must indicate his/her authorization of your employment as specified in the Employment Information by signing and dating the Parent/Guardian authorization.

5.	School Record/Issuing Officer Certification (sections E & F) - Bring the completed certification form to your school district. A designated school official will review the form and issue the working papers only after being satisfied that the working conditions and hours will not interfere with your education or damage your health. The official may refuse to issue working papers if such refusal would be in your best interest.

IMPORTANT INFORMATION

Hours of Work – 14 & 15 Year Olds
•	no more than 3 hours a day on a school day
•	no more than 18 hours a week during a school week
•	may not work before 7:00 am or after 7:00 pm during the school year
•	summer vacation: may work up to 8 hours a day, 40 hours a week, and may work up to 9:00 pm with written parental permission (which must be on file with the employer)

Hours of Work – 16 & 17 Year Olds •	no more than 8 hours a day
•	no more than 40 hours a week
•	may not work before 6:00 am or after 11:00 pm
Exception: may work after 11:00 pm (up to 3 am provided work begins before 11 pm) during regular school vacation and when there is no school the next day with written parental permission (which must be on file with the employer)

Hours of Work – All Minors
•	no more than 6 consecutive days
•	may not work more than 5 continuous hours without at least a 30-minute meal break

Hours of Work - School-Sponsored Cooperative Education Experiences, Apprenticeships and Paid Structured Learning Experiences - Training site experiences may not exceed five hours on any day that school is in session nor may the combination of school and work exceed eight hours on any day that school is in session.

Prohibited Work– Certain potentially hazardous jobs are prohibited for minors based on the age of the minor. For a complete list of prohibited occupations, visit the Department of Labor and Workforce Development’s website at www.nj.gov/labor and click on Wage & Hour.
www.nj.gov/education - New Jersey Department of Education www.nj.gov/labor (click on Wage & Hour) – New Jersey Department of Labor and Workforce

A300 (R-9-2012) New Jersey Department of Education