Permit To Employ And Work

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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

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