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A300 (State of New Jersey)

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A300 Combined Certification Form Date(s) of previously issued certificates (if applicable): ________________
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.
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
prop
osed without impairment of progress in school.
__
_______________________________________________________________
Signature of Principal Date
____
____________________________________________________________
Signature of Minor Date
________________________________________________________________
Signature of Issuing Officer Date of Issue Certificate No.
Cooperative Education Experience (CEE) - Hazardous Occupation CEE - Non-Hazardous Occupation Paid Structured Learning Experience
NEW JERSEY DEPARTMENT OF EDUCATION Date Printed: _____________
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__________________
-
A300 (R-6-16-2020) 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) - Present 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. The official may refuse to issue working papers if such refusal
would be in your best interest.*
* See above Executive Order 13 (Murphy) (2020) for temporary instructions.
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)
Pursuant to Executive Order 135 (Murphy) (2020), for the duration of the Public Health Emergency declared in Executive
Order No. 103 (2020), the provisions of N.J.S.A. 34:2-21.8 and N.J.S.A. 34:2-21.10, requiring the personal appearance of the
minor, and, under certain circumstances, the minor’s parent or guardian, before school district issuing officers in order to apply
for or sign employment certificates may be satisfied through the use of audio-visual technology. Each public-school district
shall develop and implement procedures to satisfy the statutory requirements without requiring in-person contact between the
school district issuing official and the minor, under the following conditions: a. During the application process, the child and
the school district licensing officer may transmit a single copy of all required documentation by way of electronic transmission,
fax, or any other means of transfer of documents developed by the school district that avoids in-person contact, is secure, and
maintains the confidentiality of the documents; b. The video conference shall be live and must allow for interaction between
the child and the school district issuing officer, and when applicable, the parent or guardian. During the video conference, the
child shall verify his or her identity, authenticate the documents submitted, and sign the application, in a way that is visible and
audible to the school district issuing officer; and c. Following the video conference, the child shall transmit the signed
certificate, by electronic or other means as determined by the school district, to the issuing officer, who shall make the
requisite copies and distribute the original and copies as required by N.J.S.A. 34:2-21.7
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-6-16-2020) New Jersey Department of Education
• no more than 6 consecutive days
• may not work more than 5 continuous hours without at least a 30-minute meal break
• 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 – 16 & 17 Year Olds
Hours of Work – All Minors
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A300 (State of New Jersey)

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Completed 29 April 2022

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