Application Form For Work Permit - Horizontal printable pdf download

Application Form For Work Permit - Horizontal

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.

Application Form For Work Permit - Horizontal