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Get CA CDE B1-4 2014

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 Permit Expiration Date Check Permit Type succeeding school year. Full-time exempt work permits issued to 14 15 year olds shall expire no later than the end of the current school year. EC 49118 and 49130 Full-time Work Experience Education Vocational Cooperative Education or Personal Attendant Workability Restricted General Date Minor s Information Minor s Name Print First and Last Social Security Number Home Phone Age at Time of Issuance Home Address School Information Birth Date City Zip Code School Name School Phone School Address Maximum Work Hours Permitted 1. Maximum number of work hours on a school day 3. Maximum weekly work hours while school is in session Remarks or Work Limitations This permit is valid only at the business listed below Business Address Business Name To be signed by minor Minor s Signature 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 Copy District or County Superintendent Parent or Legal Guardian Employer. California Education Code EC 49110 c Print Information Permit Expiration Date Check Permit Type succeeding school year. Full-time exempt work permits issued to 14 15 year olds shall expire no later than the end of the current school year. Full-time exempt work permits issued to 14 15 year olds shall expire no later than the end of the current school year. EC 49118 and 49130 Full-time Work Experience Education Vocational Cooperative Education or Personal Attendant Workability Restricted General Date Minor s Information Minor s Name Print First and Last Social Security Number Home Phone Age at Time of Issuance Home Address School Information Birth Date City Zip Code School Name School Phone School Address Maximum Work Hours Permitted 1. EC 49118 and 49130 Full-time Work Experience Education Vocational Cooperative Education or Personal Attendant Workability Restricted General Date Minor s Information Minor s Name Print First and Last Social Security Number Home Phone Age at Time of Issuance Home Address School Information Birth Date City Zip Code School Name School Phone School Address Maximum Work Hours Permitted 1. Maximum number of work hours on a school day 3. Maximum weekly work hours while school is in session Remarks or Work Limitations This permit is valid only at the business listed below Business Address Business Name To be signed by minor Minor s Signature Certification I hereby certify that to the best of my knowledge the information herein is correct and true. .

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