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:

 Full-time

 Workability

 Restricted

 General

 Work Experience Education, Vocational Cooperative Education, or Personal Attendant
















Date







Minor’s Information




     




     




Minor’s Name (Print First and Last)




Social Security Number




     




     




     




Home Phone




Age at Time of Issuance




Birth Date




     




     




     

Home Address




City




Zip Code

School Information

     




     




School Name




School Phone




     




     




     

School Address




City




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




Date







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


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