Permit To Employ And Work printable pdf download

Permit To Employ And Work

STATE OF CALIFORNIA

DEPARTMENT OF EDUCATION

PERMIT TO EMPLOY AND WORK

CDE B1-4 (REV. 03-10)

A work permit shall not be issued to a minor until the “Statement of Intent to Employ Minor and Request for Work Permit”

(CDE B1-1) form has been signed by the parent or guardian, foster parent, caregiver, or residential shelter service provider and filed

with the issuing authority. California Education Code (EC) 49110(c)

(Print Information)

Permit Expiration Date

Check Permit Type:

(Non full-time work permits shall expire five days after the

1. Full-time

3. Workability

opening of the next succeeding school year. Full-time work

2. Work Experience

4. Restricted

permits shall expire no later than the end of the current school

Education,

year.) EC 49118, 49130

Vocational

Education, or

Date

Personal Attendant

Minor’s Information

Minor’s Name (Print First and Last)

Social Security Number

Home Phone

Age at Time of Issuance

Birth Date

Home Address

City

Zip Code

School Information

School Name

School Phone

School Address

City

Zip Code

Maximum Work Hours Permitted

1. Total number of work hours on a school day

2. Total number of work hours on a school day preceding a non-school day

3. Total number of work hours on a non-school day

Remarks or Work Limitations:

This permit is valid only at the business listed below:

Business Name

To be signed by minor

Minor’s Signature

Date

Certification

I hereby certify that, to the best of my knowledge, the information herein is correct and true.

I hereby certify that I have a working knowledge of child labor laws and all laws pertaining to the issuance of work permits in

California. EC 49110

Issuing Authority’s Name and Title (Print)

Issuing Authority’s Signature

Date

Copy–District or County Superintendent; Parent or Legal Guardian; Employer

Permit To Employ And Work

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