Fillable Section A: Employee Information (Student) DURING SCHOOL TERM (Missouri)

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Section A: Employee Information (Student) DURING SCHOOL TERM (Missouri)

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LS-67 (10-17) AI
MISSOURI DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS
DIVISION OF LABOR STANDARDS
CERTIFICATE TO EMPLOY A CHILD 14 OR 15 YEARS OF
AGE
DURING SCHOOL TERM
P.O. Box 449
Jefferson City, MO 65102-
0449
Phone: 573-751-
3403
Fax: 573-751-
3721
Email:
laborstandards@labor.mo.gov
Website: www.labor.mo.gov/youth-
employment
Section A: Employee Information (Student)
Youth Name
Parent/Guardian Name
Home Address (Street, City, State, ZIP Code)
Home Address (Street, City, State, ZIP Code)
Parent Phone No.
Parent Email
Youth Date of Birth
Youth Age
City, State, ZIP Code
Youth Signature
Parent/Guardian Signature
Date
Section B: Employer Information (Intention to Employ)
Employer Name
Employer Email
Phone No.
Business Address (Street, City, State, ZIP Code)
Employer Fax No.
Business Type
Type of Job Offered (Include specific duties. See Chapter 294.040 of the Missouri Revised Statutes (RSMo) for prohibited occupations.)
Please check the boxes below to indicate that you understand and comply with these statutory requirements of Chapter
294, RSMo.
No more than 3 hours on any school day.
No more than 8 hours on any nonschool day.
No more than 40 hours in a week.
No more than 6 work days in a week.
Hours must be between 7 a.m. and 9 p.m. during non-school term.
Hours must be between 7 a.m. and 7 p.m. during school term.
I certify that I understand and will abide by the statutory requirements of Chapter 294, RSMo.
Employer or Authorized Agent Signature
Printed Name
Date
Section C: Issuing Officer
Name of School District (if applicable)
Proof of Child’s Age (List) _________________________________
_______________________________________________________
Certificate of Grades Reviewed
Name of Issuing Officer
Title
Fax Number
Address (Street, City, State, ZIP Code)
Issuing Officer Email
Phone Number
I certify that I understand the requirements in existing law for issuing a work certificate and find these requirements met with regard
to this statement.
Authorizing Signature: ___________________________________________ Date: ____________________
DISTRIBUTION: ORIGINAL – EMPLOYER; ONE COPY – SCHOOL DISTRICT; ONE COPY – DIVISION OF LABOR STANDARDS
LS-67-2 (10-17) AI
Instructions
Wo
rk certificates are required regardless of where a child attends school (public school, private school, charter school,
home school). Work certificates must be issued by either (1) the public school superintendent of the school district in
which the child resides, (2) the chief executive officer of the charter school that the child attends, (3) the public or private
school principal of the school that the child attends, (4) the designee of any of these school officials, or (5) if the child is
home-schooled, a parent of the child. The public school superintendent of the school district in which the child resides
may revoke a work certificate issued by a public or private school principal, if that is deemed to be in the best interest of
the child.
I
nstructions for completing the certificate are as follows:
Step 1: Complete Section A of the form, including the signature of the child’s parent or guardian.
Step 2: Take the form to the employer for completion of Section B.
No
te: Federal child labor law, while similar to the Missouri child labor laws, contains differing restrictions.
Employers should contact the U.S. Department of Labor regarding compliance with federal child labor law.
Website: https://www.dol.gov
Step 3: After Sections A and B are completed, take the form to one of the individuals identified above as having
authority to issue a work certificate for completion of Section C. The following information will also be required
at that time:
• Proof of the child’s age (birth certificate or other evidence).
A
dditionally, the following information may be required by the issuing officer:
• Attendance of a parent or guardian with the child at the time the child applies for a certificate. Check
with the issuing officer for his or her policy.
• A certificate from the principal of the school that the child attends setting out the child’s grades.
(This requirement may be waived for home-schooled children.)
• A certificate from a physician that has personally examined the child stating that the child is in g
ood
m
ental and physical health and is capable of performing labor without injury to his or her health a
nd
mental development. Check with the issuing officer for his or her policy.
Step 4: After all three sections of the form have been completed, the original must be provided to the child’s employer.
The issuing officer must retain a copy, and a copy must be mailed to:
Department of Labor and Industrial Relations
Division of Labor Standards
P.O. Box 449
Jefferson City, MO 65102-0449
O
r fax to: 573-751-3721
F
or more information on Missouri’s child labor laws contact the Division of Labor Standards:
Phone: 573-751-3403 Email: laborstandards@labor.mo.gov Website: www.labor.mo.gov
/youth-employment
Missouri Department of Labor and Industrial Relations is an equal opportunity employer/program.
TDD/TTY: 800-735-2966 Relay Missouri: 711
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Section A: Employee Information (Student) DURING SCHOOL TERM (Missouri)

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Completed 31 March 2021

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