Application Form For Work Permit - Horizontal

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Date of application
APPLICATION FOR WORK PERMIT
 
Certificate/Permit number
 
Date issued
PDE-4565 (10/91)
 
A. To be completed by issuing officer
 
Sex
Signature of issuing officer
Name of minor
Color of hair
Color of eyes
Any physical work restrictions
School district - name and address
Place of residence
Place of birth
Evidence of age accepted and filed. Evidence shall be required in the order designated. Cross out all but the one accepted.
Date of birth
a. Transcript of birth certificate
b. Baptismal certificate or transcript
c. Passport
Year
Month Day
d. Other documentary evidence
e. Affidavit of parent or guardian accompanied by physician’s
statement of opinion as to the age of the minor
B. To be completed by parent or guardian, unless minor is a high school graduate (please attach proof of graduation)
Name and address of parent, guardian or legal custodian
Signature of parent, guardian or legal custodian *
 
 
Commonwealth of Pennsylvania - Department of Education
 
 
*In lieu of a signature under clause (B), the applicant may execute a statement before a notary public or other person authorized to administer oaths 
attesting to the accuracy of the facts set forth in the application on a form prescribed by the department. The statement shall be attached to the 
application.

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