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Work Permit Request Form
To complete your request for a work permit, please email a photo of your signed "Statement of Intent to Employ a Minor and Request for a Work Permit-Certificate of Age CDE Form B1-1" to Mrs. Smith at
marjeri.smith@smusd.org
.
Applications can be found at
https://www.dir.ca.gov/dlse/dlseformB1-1.pdf
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* Indicates required question
Email
*
Your email
Student's First Name
*
Your answer
Student's Last Name
*
Your answer
Student's ID Number
*
Your answer
Grade Level
*
9th
10th
11th
12th
Last 4 Digits of your Social Security Number
*
Your answer
Home Phone Number
*
Your answer
Age
*
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Home Address
*
Your answer
City, Zip Code
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Your answer
Business (Employer) Name
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Your answer
Business (Employer) Address
*
Your answer
Business (Employer) City, Zip Code
*
Your answer
My work permit application has been completed and signed by my parent/guardian and my employer.
*
Yes
No
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