Statement Of Intent To Employ Minor And Request For Work Permit
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3Statement of Intent to Employ Minor and Request for Work Permit
Not a work permit —Print all information except signatures
For Minor to Complete
Minor’s name (last name first)
Social security number
Date of birth
Age
Grade
Street address
City
ZIP Code
Home telephone
School name
Street address
City
ZIP Code
School telephone
For Employer to Complete
(Please review rules for employment of minors on reverse.)
Name of business
Street address
City
ZIP Code
Business telephone
Minor’s work duties
Hourly wage
Maximum number of hours of employment when school is in session:
0.00
Mon.
Tues.
Wed.
Thurs.
Fri.
Sat.
Sun.
Weekly =
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.
Supervisor’s signature
Supervisor’s name (print or type)
For Parent or Guardian to Complete
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, the information herein is correct and true. I request that a work permit be issued.
In addition to this employer, my child is working for:
Name of business
Signature of parent or legal guardian
Date
For School to Complete
Type:
Regular
Evidence of minor’s age
Vacation
Year-Round
Signature of verifying authority
Work Experience Education
Other (specify)
CALIFORNIA DEPARTMENT OF EDUCATION FORM B1-1 (revised 6/03)
IMPORTANT: See reverse side for additional information.
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