Attendant
Counselor: ___________________ SID#: __________________________ Grade: ________

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 Information

Minor’s Name (First and Last)

Home Address

Home Phone

City

Grade

Zip Code

Birth Date	Social Security Number	Age	Student’s Signature

School Information
	
	Clovis East High School
		(559)327-4000

School Name

2940 Leonard Ave. School Address

School Phone

Clovis City

93619 Zip Code

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

To be filled in and signed by employer

_____
					
Business Name or Agency of Placement
		Business Phone
			Su
	pervisor’s Name
	
Business Address Employer’s Maximum Expected Work Hou
Describe nature of work to be performed:
	
rs: ____
		City
hours per day ________ hours per week
		Zip Code

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
		Date

For authorized work permit issuer use ONLY
	
Maxi
	mum number of work hours when school is in sessio

Tues	Wed	Thur	Fri	Sat	Sun

__________________________________________ f of Minor’s Age (Evidence Type)

_________________________________________ ying Authority’s Name and Title (Print)

__________________________________________ ying Authority’s Signature
	n:
	Maximum number of work hours when school is not in sessi

	Mon 	Tues 	Wed  Thur	Fri	     Sat 	Sun  

Check Permit Type:	Work Experience
Full-time                                   Education, Vocational Restricted                                  Education, or Personal

General	Workability
	on:

 
	
Mon

____ Proo

____ Verif

____ Verif
		Total
		 Total

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.