APPLICATION FOR WORK PERMIT
Date of application ______________________________________
Certificate/Permit number ________________________________
PDE‐4565 (1/13)
Date issued _____________________________________________
A. To be completed by issuing officer
Name of minor Sex_____________________________
Color of hair _____________________
Color of eyes ____________________
Signature of issuing officer
Any physical work restrictions School district‐ name and address
Place of residence Place of birth
Date of birth Evidence of age accepted and filed. Evidence shall be required in the order designated. Cross out all but the one accepted.
a. Transcript of birth certificate b. Baptismal certificate or transcript c. Passport
d. Other documentary evidence e. Affidavit of parent or guardian accompanied by
physician's statement of opinion as to the age of the minor
Month Day Year
B. To be completed by parent or guardian, unless minor is a high school graduate (please attach proof of graduation)
Signature of parent, guardian or legal custodian* Name and address of parent, guardian or legal custodian
Commonwealth of Pennsylvania‐ Department of Education
*In lieu of signature under clause (B), the applicant may execute a statement before a notary public or other person authorized to
administer oaths attesting to the accuracy of the facts set forth in the application on a form prescribed by the department. The
statement shall be attached to the application.
APPLICATION FOR WORK PERMIT
Date of application ______________________________________
Certificate/Permit number ________________________________
PDE‐4565 (1/13)
Date issued _____________________________________________
A. To be completed by the applicant
Name of minor Sex_____________________________
Color of hair _____________________
Color of eyes ____________________
Signature of issuing officer
Any physical work restrictions School district‐ name and address
Place of residence Place of birth
Date of birth
Evidence of age accepted and filed. Evidence shall be required in the order designated. Check the accepted evidence.
a. Transcript of birth certificate b. Baptismal certificate or transcript c. Passport
d. Other documentary evidence e. Affidavit of parent or guardian accompanied by
physician's statement of opinion as to the age of the minor
Month Day Year
B. To be completed by parent or guardian, unless minor is a high school graduate (please attach proof of graduation)
Signature of parent, guardian or legal custodian* Name and address of parent, guardian or legal custodian
Commonwealth of Pennsylvania‐ Department of Education
*In lieu of signature under clause (B), the applicant may execute a statement before a notary public or other person authorized to
administer oaths attesting to the accuracy of the facts set forth in the application on a form prescribed by the department. The
statement shall be attached to the application.
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