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[PDF] Work Permit - California Department of Industrial Relations - CAgov

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General

STATE OF CALIFORNIA DEPARTMENT OF EDUCATION

STATEMENT OF INTENT TO EMPLOY

MINOR AND REQUEST FOR

WORK PERMIT

CERTIFICATE OF AGE CDE Form B1-1 (Rev. 02-14)

A "

STATEMENT OF INTENT

TO EMPLOY A MINOR AND REQUEST FOR

WORK PERMIT

CERTIFICATE OF AGE

form ( CDE Form B1

1) shall be completed in accordance with California

Education Code

49162 and 49163 as notification of intent to

employ a minor. This form is also a Certificate of Age pursuant to California

Education Code

49114.

(Print Information)

Minor's Information

Minor's Name (First and Last) Home Phone Grade

Home Address City Zip Code

Birth Date

School Information

Social Security Number

Age Student's Signature

School Name School Phone

School Address City Zip Code

To be filled in and signed by parent or legal guardian 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 and belief, the information herein is correct and true. Parent's Name (Print First and Last) Parent's Signature Date

To be filled in and signed by employer

Business Name or Agency of

Placement

Business Phone Supervisor's Name

Business Address

City Zip Code

Employer"s Maximum Expected Work Hours: _________ hours per day ________ hours per week

Describe nature of work to be performed:

In compliance with California labor laws, this employee is covered by workers compensation insurance. T his 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. Employer's Name (Print First and Last) Employer's Signature Date

For authorized work permit issuer use ONLY

Maximum number of work hours when school is in session:

Mon Tues Wed Thur Fri Sat Sun Total

______________________________________________

Proof of Minor's

A ge (Evidence Type _____________________________________________

Verifying Authority's Name and Title

(Print) ______________________________________________

Verifying Authority's Signature

Maximum number of work hours when school is not in session:

Mon Tues Wed Thur Fri Sat Sun Total

Check Permit Type:

Full time

Restricted

Work Experience

Education, Vocational

Education, or Personal

Attendant

Workability

For more information about child labor laws, contact the U.S. Department of Labor at http://www.dol.gov/, and the State of

California Department of Industrial Relations, Division of Labor Standards E nforcement at http://www.dir.ca.gov/DLSE/dlse.htmlquotesdbs_dbs11.pdfusesText_17

[PDF] [PDF] Work Permit - California Department of Industrial Relations - CAgov

General

STATE OF CALIFORNIA DEPARTMENT OF EDUCATION

STATEMENT OF INTENT TO EMPLOY

MINOR AND REQUEST FOR

WORK PERMIT

CERTIFICATE OF AGE CDE Form B1-1 (Rev. 02-14)

STATEMENT OF INTENT

TO EMPLOY A MINOR AND REQUEST FOR

WORK PERMIT

CERTIFICATE OF AGE

1) shall be completed in accordance with California

Education Code

49162 and 49163 as notification of intent to

Education Code

49114.

Minor's Information

Minor's Name (First and Last) Home Phone Grade

Home Address City Zip Code

Birth Date

School Information

Social Security Number

Age Student's Signature

School Name School Phone

School Address City Zip Code

I hereby certify that to the best of

To be filled in and signed by employer

Business Name or Agency of

Placement

Business Phone Supervisor's Name

Business Address

City Zip Code

Describe nature of work to be performed:

For authorized work permit issuer use ONLY

Mon Tues Wed Thur Fri Sat Sun Total

Proof of Minor's

Verifying Authority's Name and Title

Verifying Authority's Signature

Mon Tues Wed Thur Fri Sat Sun Total

Check Permit Type:

Restricted

Work Experience

Education, Vocational

Education, or Personal

Attendant

Workability