Application Form For Work Permit - Commonwealth Of Pennsylvania printable pdf download

APPLICATION FOR WORK PERMIT

Date of application ______________________________________

Certificate/Permit number ________________________________

Date issued _____________________________________________

PDE‐4565 (1/13)

A. To be completed by issuing officer

Name of minor

Sex_____________________________

Signature of issuing officer

Color of hair _____________________

Color of eyes ____________________

Any physical work restrictions

School district ‐ name and address

Place of residence

Place of birth

Date of birth

Evidence of age accepted and filed. Evidence shall be required in the order designated. Cross out all but the one accepted.

a. Transcript of birth certificate

b. Baptismal certificate or transcript

c. Passport

Month

Day

Year

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)

Signature of parent, guardian or legal custodian*

Name and address of parent, guardian or legal custodian

Commonwealth of Pennsylvania ‐ Department of Education

*In lieu of 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.