Child Labor Act Complaint

This form is used for complaints under the Pennsylvania Child Labor Act of 2012, P.L. 1209, No. 151.

Claimant Information First Name  Initial      Last Name
Address - Line 1    Address - Line 2   City  State  Zip Code	() Area    Daytime Telephone     () Area   Evening Telephone    () Area   Fax    E-Mail

Minor Information
	Enter information relating to the involved Minor(s) (under the age of 18) in the area provided below. Include Name, Address, Telephone Number, Age and/or Date of Birth (if known).

Employer Information   First Name of Contact Person   Initial       Last Name of Contact Person First Name of Owner   Initial       Last Name of Owner
Company Name     Address - Line 1    Address - Line 2   City  State  Zip Code	() Area     Telephone       Adams Allegheny Armstrong Beaver Bedford Berks Blair Bradford Bucks Butler Cambria Cameron Carbon Centre Chester Clarion Clearfield Clinton Columbia Crawford Cumberland Dauphin Delaware Elk Erie Fayette Franklin Forest Fulton Greene Huntingdon Indiana Jefferson Juniata Lackawanna Lancaster Lawrence Lebanon Lehigh Luzerne Lycoming McKean Mercer Mifflin Monroe Montour Montgomery Northampton Northumberland Perry Philadelphia Pike Potter Schuylkill Snyder Somerset Sullivan Susquehanna Tioga Union Venango Warren Washington Wayne Westmoreland Wyoming York County

	Do you wish to remain anonymous?YesNo

Violations
	1.	Are minors employed under the age of 14 years old?		YesNo
		If Yes, please explain:
	2.	Are minors employed with working papers officially called Employment Certificates?		YesNo
	3.	Are minors employed more than 8 hours a day?		YesNo
	4.	Are minors employed in what may be excessive hours per week?		YesNo
		If Yes, please explain:
	5.	Are minors employed under age of 18 years old?		YesNo
	6.	Are minors employed in a prohibited occupation?		YesNo
		If Yes, please explain:
	7.	Are minors employed more than 5 hours without 30 min. "Break"?		YesNo
		If Yes, please explain:
	8.	Are minors employed late at night; either during school or summer vacation?		YesNo
		If Yes, please explain:
	9.	Are minors employed during very early or odd hours of the morning?		YesNo
		If Yes, please explain:
	10.	Please explain any additional needed information which may be helpful to complete the investigation of this complaint

I hereby certify that to the best of my knowledge and behalf, the above information is a true statement of facts relating to the alleged Violation(s) of the Child Labor Act of the Commonwealth of Pennsylvania.

The Bureau will contact you for any further information. Please notify the Bureau if there is a change of address or telephone by which to contact you.