In navigating the complexities of employing minors, the PDE-4565 form serves as a cornerstone document, ensuring compliance with both state and federal regulations concerning child labor. This application for employment certificate or transferable work permit, delineated by the Commonwealth of Pennsylvania's Department of Education, stands as a pivotal step in the employment process of minors, offering a structured format for documenting essential information. It collects data starting from basic identifiers related to the minor—such as name, sex, physical characteristics, and residency—to more intricate details that include the type of employment certificate requested, parent or guardian consent, prospective employment details, and the hours of employment permissible under the law. Moreover, the form incorporates a section designated for a physician, certified nurse practitioner, or certified registered nurse practitioner to document health qualifications of the minor for the specified employment, in accordance with health standards laid out by the board of school directors or the minor’s own family physician endorsed by the prospective employer. This form not only encapsulates a procedure for lawful employment of minors but also underscores the importance of safeguarding their health and educational commitments, evidenced through its endorsements of age verification, informed parental or guardian consent, and medical fitness, structured within the legislative framework of the Child Labor Law, Act of May 13, 1915, as amended.
| Question | Answer |
|---|---|
| Form Name | Form PDE-4565 |
| Form Length | 1 pages |
| Fillable? | Yes |
| Fillable fields | 21 |
| Avg. time to fill out | 4 min 31 sec |
| Other names | form pde 4565 10 91, application for employment certificate, undersigned, TRANSFERABLE |
APPLICATION FOR EMPLOYMENT CERTIFICATE
OR TRANSFERABLE WORK PERMIT
Date of Application ________________
Certificate/Permit Number __________
Date Issued _____________________ |
A. To be completed by issuing officer
Name of Minor
Sex ____________
Color of Hair ____________
Color of Eyes ____________
Signature of Issuing Officer
Any Distinguishing Characteristics:
Place of Residence
School District – Name and Address
Date of Birth
Month Day Year
Evidence of age accepted and filed. Evidence shall be required in the order designated. Cross out all but one accepted.
a. Transcript of birth certificate d. Other documentary evidence
B. To be completed by parent guardian or legal custodian in presence of issuing officer
I, the parent, guardian or legal custodian of the
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Mark only one |
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________ |
General Employment Certificate |
________ |
Transferable Work Permit (in lieu of General Employment Certificate |
________ |
Vacation Employment Certificate |
________ |
Transferable Work Permit (in lieu of Vacation Employment Certificate |
Signature of Parent, Guardian or Legal Custodian |
Name and Address of Parent, Guardian or Legal Custodian |
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C.To be completed by prospective employer
The undersigned expects to employ the minor as ___________________ in the industry of ________________________
(type of work)(type of industry)
The minor will work during such times and in accordance with the maximum hours permissible by law as established by Section 4 and 12 of the Child Labor Law, Act of May 13, 1915, P.L. 286; No. 177, as amended.
*Hours of employment – Ages 14 & 15
Maximum 3 hours on school days
Maximum 18 hours per week Maximum 8 hours per nonschool week
Summer Vacation Maximum 8 hours per day Maximum 40 hours per week
Night Work
School term – may not work after 7 p.m. or before 7 a.m.
Exception – Summer Vacation until 9 p.m. but not before 7 a.m.
* Federal Law
Hours of employment – Ages 16 & 17 Maximum 8 hours on any given day Maximum 28 hours
an additional 8 hours on Sunday. Maximum 44 hours per week.
Summer Vacation
Maximum 8 hours per day, 44 hours per week
Night Work
School term – May not work after midnight Sunday through Thursday or before 6 a.m. any day.
Exception – Preceding nonschool day 1 a.m. No limits during summer.
Employer: Within the limitations as identified in “Hours of Employment,” please fill out the following:
Sun |
Mon |
Tue |
Wed |
Thur |
Fri |
Sat |
__hrs __hrs __hrs __hrs __hrs __hrs __hrs
Maximum hours: per day ____ per week ____
Name, address and telephone number of employer:
____________________________
____________________________
____________________ Zip ________
Signature of Owner or Manager:
____________________________
D.To be completed by examining physician, certified nurse practitioner or certified registered nurse practitioner employer by the board of school directors, by the minor’s family physician designated by the prospective employer.
I hereby certify that the minor named on this form has been thoroughly examined and:
_____ is physically qualified for the employment specified in the statement of the prospective employer.
_____ is physically qualified for the period of _______, after which time a new examination is required.
_____ s physically qualified with the following limitations: ________________________________________________.
Signature of Examiner:
Address of Examiner:
Commonwealth of Pennsylvania – Department of Education