Application with School Record DLSE277A PDF

STATE OF CALIFORNIA DEPARTMENT OF EDUCATION

A “STATEMENT OF INTENT TO EMPLOY A MINOR AND REQUEST FOR A WORK PERMIT–CERTIFICATE OF AGE” form (CDE Form B1-1) shall be completed in accordance with

Request for Work Permit - Work Experience (CA Dept of Education)

A “STATEMENT OF INTENT TO EMPLOY A MINOR AND REQUEST FOR WORK PERMIT–CERTIFICATE OF AGE” form. (CDE B1-1) shall be completed in accordance with California

Request for Work Permit - Work Experience (CA Dept of Education)

STATE OF CALIFORNIA DEPARTMENT OF EDUCATION. STATEMENT OF INTENT TO EMPLOY A MINOR AND REQUEST FOR A WORK PERMIT–CERTIFICATE OF AGE. CDE Form B1-1 (Rev.

IMM 5488 E : DOCUMENT CHECKLIST FOR A WORK PERMIT

FOR A WORK PERMIT (APPLIED OUTSIDE CANADA). IMM 5488 (02-2022) E. This document checklist is one of the forms that you need to submit with your application.

PERMIT TO EMPLOY AND WORK

STATE OF CALIFORNIA DEPARTMENT OF EDUCATION A work permit shall not be issued to a minor until the “STATEMENT OF INTENT TO EMPLOY A MINOR AND REQUEST ...

Application with School Record DLSE277A

To make a request to access such records please contact the Entertainment Work Permit Unit by email EWP@dir.ca.gov or telephone. 818-901-5484. WATERMARK-277-A.

child labor laws 2 0 1 3

Emancipated minors are subject to all California's child labor laws except that they may apply for a work permit without their parents' permission. [FC 7050] (

Junior Permit Statement of Facts

CURRENT CA ID NUMBER. SECTION 2 — REASON(S) JUNIOR PERMIT REQUIRED. CHECK ALL THAT APPLY. I. Family Illness. II. School. III. To and From Work.

Work Permits During 2020-2021 The Santa Barbara Unified School

permit applications from scanned or e-signed documents at this time?. Additionally by law

State of Michigan Combined Offer of Employment and Work Permit

CA-7 for minors 16 and 17 years of age. Employer Information: • The employer must have a completed work permit form on file before a minor begins work.

S E C T I O N A Date of Birth Height Weight Hair Color Eye Color Gender

SCHOOL RECORD

** Please CHECK the best description of the minor for each **

SATISFACTORY

UNSATISFACTORY SATISFACTORY UNSATISFACTORY

Please indicate if the minor requires medical

approval to obtain a permit

REQUIRED NOT NEEDED

Certification:

I certify that the above-named minor meets the

school district's requirements with respect to age, school record and health AGREE

DISAGREE

Signature and Title of Authorized

School Official

Date Signed

School Address

Daytime Phone

[School Seal/Stamp or Address Stamp](REQUIRED) ** All Areas Must state SATISFACTORY for issuance of permit ** ** Any alterations or falsifications may void this application ** S E C T I O N D

Certified Birth Certificate

2.Baptismal Certificate

3.Official letter from hospital where born

4.Passport

(Grades 1 through 12)

When school is IN session, the application must be completed and dated during the current school session by an authorized school

official.

When school is NOT in session (i.e., school break, vacations, holidays), either the minor"s recent report card or letter from the school

principal on school letterhead indicating that the minor is satisfactory" in all academic subjects, health and attendance is required.

If minor is homeschooled, the application must be completed by the parent/guardian and attached to either a current private school

affidavit, or written verification indicating that the minor is satisfactory" in all academic subjects, health and attendance from either the

local school district, county office of education or state board of education where the minor lives. INFORMATION PRACTICES ACT NOTICE (California Civil Code Section 1798.17)

1.The information on this application is being requested by the Department of Industrial Relations, Division of Labor Standards Enforcement.

2.The information in this application is collected and maintained pursuant to California Labor Code sections 1308.5, 1308.10 and Title 8

California Code of Regulations section 11753.

3.If you fail to provide all or any part of the information requested in this application, the Labor Commissioner may deny issuance / renewal of anEntertainment Work Permit for minors under 18 years of age.

4.The principal purposes within the Division of Labor Standards Enforcement for which the information on this application will be used are: (1)administration of the registration for the employment of minors in the entertainment industry, and (2) enforcement of the California child labor

laws.

5.The following are known or foreseeable disclosures of the information contained herein which may be made pursuant to subdivision (e) or (f)of Section 1798.24 of the California Civil Code by the Division of Labor Standards Enforcement. Response to a request under the California

Public Records Act.

6.You have the right to access records containing your personal information that are maintained by the Division of Labor Standards Enforcement.

To make a request to access such records, please contact the Entertainment Work Permit Unit by email EWP@dir.ca.gov or telephone

818-901-5484.

WATERMARK-277-A

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[PDF] Application with School Record DLSE277A