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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 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 Information Minor s Name First and Last Home Phone Grade Home Address City Zip Code Birth Date School Information Social Security Number School Name Student s Signature Age School Phone School Address 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 Date Business Name or Agency of Placement Supervisor s Name Business Phone Business Address 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 Proof of Minor s Age Evidence Type Verifying Authority s Name and Title Print Total Check Permit Type Restricted Work Experience Education Vocational Education or Personal Attendant General Workability Full-time 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. This form is also a Certificate of Age pursuant to California Education Code 49114. Print Information Minor s Information Minor s Name First and Last Home Phone Grade Home Address City Zip Code Birth Date School Information Social Security Number School Name Student s Signature Age School Phone School Address 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. 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 Date Business Name or Agency of Placement Supervisor s Name Business Phone Business Address 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. .