Copies of this TEMPORARY employment certificate shall be provided to the employer, Illinois
Department of Labor, the minor's parent or legal guardian and the issuing officer shall also retain a
copy on file. Any employer, upon termination of the employment shall immediately return the
certificate
issued to the issuing officer as required by Section 13 of the CLL.
By accepting and submitting this form, the issuing officer affirms and certifies that all information
provided and the statements made herein are true, correct and complete. It also confirms
participation by the parent or legal guardian in the application process.
Illinois Department of Labor
Date of Issue:
____________
Temporary Child Performer Employment Certificate
VALID FOR ONLY 15 DAYS FROM DATE OF ISSUE AND FOR EMPLOYER TO WHOM ORIGINALLY
ISSUED. NO MORE THAN ONE TEMPORARY CERTIFICATE MAY BE ISSUED TO EACH CHILD
PERFORMER.
Pursuant to Section 12.5 of the Child Labor Law (CLL), 820 ILCS 205, the issuing of this employment
certificate is only valid for 15 days from the date of issue. It is not renewable. The employer is required
to keep this completed form on file.
The MINOR to whom this certificate is issued:
(First Name) (Middle Name)
(Street Address)
(Last Name)
Sex:
(City) (State) (Zipcode)
Business Telephone
________________________________________________________________________________________________
Parent’s/Legal Guardians name
The Employer who intends to employ said MINOR:
Business Name
(Street Address)
(City)
(State) (Zipcode) Business Telephone
Occupation of Minor:
School Name of Issuing Officer
Issuing Officer Address (street, city, state ,zip)
(Printed Name of Issuing Officer)
The issue officer confirms that one of the following was conducted:
Distribution: Hard Copy to Employer Hard Copy to Parents/Legal Guardian
Form IL452FL04 (08/02/2021)
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