STATE OF CALIFORNIA DEPARTMENT OF EDUCATION
PERMIT TO EMPLOY AND WORK CDE Form B1-4 (REV. 02-14)
A work permit shall not be issued to a minor until the “STATEMENT OF INTENT TO EMPLOY A MINOR AND REQUEST FOR A WORK PERMIT–CERTIFICATE OF AGE” (CDE From 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)
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Permit Expiration Date |
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Check Permit Type: |
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Work permits shall expire five days after the opening of the next |
Full-time |
Work Experience Education, |
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succeeding school year. Full-time exempt work permits issued to 14 |
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Vocational Cooperative |
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& 15 year olds shall expire no later than the end of the current school |
Workability |
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year. EC 49118 and 49130 |
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Education, or Personal Attendant |
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Restricted |
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General |
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Date |
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Minor’s Information |
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Minor’s Name (Print First and Last) |
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Social Security Number |
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Home Phone |
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Age at Time of Issuance |
Birth Date |
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Home Address |
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City |
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Zip Code |
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School Information |
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School Name |
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School Phone |
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School Address |
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City |
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Zip Code |
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Maximum Work Hours Permitted
1.Maximum number of work hours on a school day
2.Maximum number of work hours on a non-school day
3.Maximum weekly work hours while school is in session
4.Maximum weekly work hours while school is not in session
Remarks or Work Limitations:
This permit is valid only at the business listed below:
Business Name |
Business Address |
To be signed by minor
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