Permit to Employ and Work

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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
Work permits shall expire five days after the opening of the next 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

Check Permit Type:





 Work Experience Education, Vocational Cooperative Education, or 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


Zip Code

School Information



School Name

School Phone




School Address


Zip Code

Maximum Work Hours Permitted

  1. Maximum number of work hours on a school day


  1. Maximum number of work hours on a non-school day


  1. Maximum weekly work hours while school is in session


  1. 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

Minor’s Signature



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


Copy–District or County Superintendent; Parent or Legal Guardian; Employer

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