General
STATE OF CALIFORNIA DEPARTMENT OF EDUCATION
STATEMENT OF INTENT TO EMPLOY A MINOR AND REQUEST FOR A WORK PERMIT–CERTIFICATE OF AGE
CDE Form B1-1 (Rev. 02-14)
A “STATEMENT OF INTENT TO EMPLOY A MINOR AND REQUEST FOR A WORK PERMIT–CERTIFICATE OF AGE”
form (CDE Form B1-1) shall be completed in accordance with California Education Code 49162 and 49163 as notification of intent to
employ a minor. This form is also a Certificate of Age pursuant to California Education Code 49114.
(Print Information)
Minor’s Name (First and Last)
School Information
Social Security Number
To be filled in and signed by parent or legal guardian
This minor is being employed at the place of work described with my full knowledge and consent. I hereby certify that to the best of
my knowledge and belief, the information herein is correct and true.
Parent’s Name (Print First and Last)
Parent’s Signature
To be filled in and signed by employer
Business Name or Agency of Placement Business Phone Supervisor’s Name
Business Address City Zip Code
Employer’s Maximum Expected Work Hours: _________ hours per day ________ hours per week
Describe nature of work to be performed:
In compliance with California labor laws, this employee is covered by workers’ compensation insurance. This business does not
discriminate unlawfully on the basis of race, ethnic background, religion, sex, sexual orientation, color, national origin, ancestry, age,
physical handicap, or medical condition. I hereby certify that, to the best of my knowledge, the information herein is correct and true.
Employer’s Name (Print First and Last)
Employer’s Signature
For authorized work permit issuer use ONLY
Maximum number of work hours when school is in session:
Mon Tues Wed Thur Fri Sat Sun Total
______________________________________________
Proof of Minor’s A
ge (Evidence Type)
_____________________________________________
Verifying Authority’s Name and Title (Print)
______________________________________________
Verifying Authority’s Signature
Maximum number of work hours when school is not in session:
Mon Tues Wed Thur Fri Sat Sun Total
Check Permit Type:
Full-t
ime
Restricted
Work Experience
Education, Vocational
Education, or Personal
Attendant
Workability
For
more information about child labor laws, contact the U.S. Department of Labor at http://www.dol.gov/, and the State of
California Department of Industrial Relations, Division of Labor Standards Enforcement at http://www.dir.ca.gov/DLSE/dlse.html.
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