Fillable Statement of Intent to Employ Minor and Request

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Statement of Intent to Employ Minor and Request

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Statement of Intent to Employ Minor and Request for Work Permit
Not a work permit —Print all information except signatures
For Minor to Complete
Minor’s name (last name first)
Social security number
Date of birth
Age
Grade
Street address
ZIP Code
Home telephone
School name
Street address
ZIP Code
School telephone
For Employer to Complete (Please review rules for employment of minors on reverse.)
Name of business
Street address
ZIP Code
Business telephone
Minor’s work duties
Hourly wage
Maximum number of hours of employment when school is in session:
Mon.
Tues.
Wed.
Thurs.
Fri.
Sat.
Sun.
Weekly =
In compliance with California labor laws, this employee is covered by worker’s 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.
Supervisor’s signature
Supervisor’s name (print or type)
For Parent or Guardian to Complete
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, the information herein is correct and true. I request that a work permit be issued.
In addition to this employer, my child is working for:
Name of business
Signature of parent or legal guardian
Date
For School to Complete
Type:
Regular
Evidence of minor’s age
Vacation
Year-Round
Signature of verifying authority
Other (specify)
CALIFORNIA DEPARTMENT OF EDUCATION FORM B1-1 (revised 6/03)
IMPORTANT: See reverse side for additional information.
Write number in after printing
0.00
General Summary of Minors’ Work Regulations
• If federal laws, state laws and school district policies
conflict, the more restrictive law (the one most
protective of the employee) prevails.
• Generally, minors must attend school until age 18 unless
they are 16 years or older and have graduated from high
school or received a state Certificate of Proficiency.
• Employers of minors required to attend school must
complete a “Statement of Intent to Employ Minor and
Request for Work Permit” (form B1-1) for the school
district of attendance for each such minor.
• Employers must retain a “Permit to Employ and Work”
(form B1-4) for each such minor.
• Work permits (B1-4) must be retained for three years and
be available for inspection by sanctioned authorities at all
times.
• A work permit (B1-4) must be revoked whenever the
issuing authority determines the employment is illegal or
is impairing the health or education of the minor.
Minors under the age of 18 may not work in environments
declared hazardous or dangerous for young workers as
listed below:
1. Explosive exposure
2. Motor vehicle driving/outside helper
3. Coal mining
4. Logging and sawmilling
5. Power-driven woodworking machines
6. Radiation exposure
7. Power-driven hoists/forklifts
8. Power-driven metal forming, punching, and shearing
machines
9. Other mining
10. Power-driven meat slicing/processing machines
11. Power-baking machines
12. Power-driven paper products/paper bailing machines
13. Manufacturing brick, tile products
14. Power saws and shears
15. Wrecking, demolition
16. Roofing
17. Excavation operation
For more complete information about hazardous occupations,
contact the U.S. Department of Labor (Child Labor Bulletins
101 and 102) and the California Department of Industrial
Relations, Division of Labor Standards Enforcement. Regional
offices are located in several California cities. They are listed
in the “Government Listings” sections of telephone
directories.
• Minors younger than 16 years are allowed to work only in
limited, specified occupations that exclude baking,
manufacturing, processing, construction, warehouse, and
transportation occupations.
• In addition to safety regulations, labor laws applicable to
adult employees also generally apply to minor employees,
including workers’ compensation insurance requirements.
• Child labor laws do not generally apply to minors who
deliver newspapers or work at odd jobs, such as yard
work and baby-sitting, or in private homes where the
minor is not regularly employed.
• A day of rest from work is required if the total hours
worked per week exceed 30 or if more than 6 hours are
worked on any one day during the week.
Ages Hours of Work
16 – 17 When school is in session: Daily maximum of 4
hours, Monday through Thursday. May work up
to 8 hours on any non-school day or on any day
that precedes a non-school day. May be
permitted to work up to 48 hours per week.
Students in Work Experience Education or
cooperative vocational education programs may
be permitted to work a maximum of 8 hours on a
school day.
When school not in session: May work up to 48
hours per week but no more than 8 hours in any
one day.
Work must be performed no earlier than 5 a.m.
or later than 10 p.m. except that work may
extend to 12:30 a.m. on nights preceding non-
school days. Students in Work Experience
Education or cooperative vocational education
programs may be authorized to work until 12:30
a.m. on nights preceding school days with
specified written permission.
14 – 15 When school is in session: On school days daily
maximum 3 hours. On non-school days may
work 8 hours. Weekly maximum of 18 hours.
Students in Work Experience Education and
career exploration programs may work up to 23
hours per week.
When school is not in session: Daily maximum 8
hours and weekly maximum 40 hours.
May not work during public school hours except
students in Work Experience Education or career
exploration programs.
Work must be performed no earlier than 7 a.m.
nor later than 7 p.m. any day of the week. From
June 1 to Labor Day work hours may be
extended to 9 p.m.
Younger Labor laws generally prohibit nonfarm
than 14 employment of children younger than 14.
Special rules apply to agricultural work,
domestic work and the entertainment industry.
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Statement of Intent to Employ Minor and Request

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Completed 27 May 2021

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