State Of California Department Of Education Statement Of Intent To Employ A Minor And Request For Work Permit- Certificate Of Age
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1
2STATE OF CALIFORNIA
DEPARTMENT OF EDUCATION
STATEMENT OF INTENT TO EMPLOY A MINOR AND REQUEST FOR WORK PERMIT–
CERTIFICATE OF AGE
CDE B1-1 (Rev. 07-10)
A “STATEMENT OF INTENT TO EMPLOY A MINOR AND REQUEST FOR WORK PERMIT–CERTIFICATE OF AGE” form
(CDE B1-1) shall be completed in accordance with California Education Code 49162 and 49163 as notification of intent to employ a
minor. This form is also a Certificate of Age pursuant to California Education Code 49114.
(Print Information)
Minor’s Information
Minor’s Name (First and Last)
Home Phone
Birth Date
Social Security Number
Grade
Age
Home Address
City
Zip Code
School Information
School Name
School Phone
School Address
City
Zip Code
To be filled in and signed by employer. (Please review the General Summary of Minors’ Work Regulations on reverse.)
Supervisor’s Name
Business Name or Agency of Placement
Business Phone
Business Address
City
Zip Code
Describe nature of work to be performed:
In compliance with California labor laws, this employee is covered by worker’s compensation insurance. This business does not
discriminate unlawfully on the basis of race, ethnic background, religion, sex, sexual orientation, color, national origin, ancestry, age,
physical handicap, or medical condition. I hereby certify that, to the best of my knowledge, the information herein is correct and true.
Employer’s Name (Print First and Last)
Employer’s Signature
Date
To be filled in and signed by parent or legal guardian
This minor is being employed at the place of work described with my full knowledge and consent. I hereby certify that to the best of my
knowledge and belief, the information herein is correct and true. I request that a work permit be issued.
Parent or Legal Guardian’s Name (Print First and Last)
Parent or Legal Guardian’s Signature
Date
For authorized work permit issuer use ONLY
Maximum number of hours of employment when school is in session:
Mon
Tue
Wed
Thu
Fri
Sat
Sun
Total
Check Permit Type:
*
***
Full-time
Work Experience
Proof of Minor’s Age (Evidence Type)
Education, Vocational
**
Workability
Education, or Personal
Attendant
Restricted
Verifying Authority’s Name and Title (Print)
General
Verifying Authority’s Signature
*
**
***
EC 49130 |
Permit Type defined by local school |
Special Education Grant
Copy–District or County Superintendent; Employer; Parent or Legal Guardian
(Over)
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