Statement of Intent to Employ a Minor and Request for a Work Permit - Certificate of Age (CDE Form B1-1)

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Statement of Intent to Employ a Minor and Request for a Work Permit - Certificate of Age (CDE Form B1-1) - Employer Section

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 sections 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.

Email *

Name of Employer Representative Completing Form *

Email Address *

Student's Last Name *

Student's First Name *

Business Name or Agency of Placement *

Business Phone *

Supervisor's Name *

Supervisor's Email Address *

Supervisor's Phone Number *

Business Street Address *

Business City, State, Zip Code *

Employer's maximum expected work hours (number per day, number per week) - Note that, although schools are not physically open, they are still in session for purposes of work hour limits. These limits are: 12-13 years old: May only work on weekends and school holidays. May not work on school days. 14-15 years old: On weekends and school holidays, may work 8 hours per day. On school days, may only work 3 hours per day. 16-17 years old: On weekends, school holidays, and days preceding weekends and school holidays, may work 8 hours per day. On other school days, may only work 4 hours per day. *

Describe the nature of work to be performed, including job duties and the department that the student will be in: *

Select one of the following: *

Employer will allow student to complete all work duties from the student’s home.

Employer will require student to leave home in order to complete work duties.

If the employer will require student to leave home, Employer is exempt from California’s Shelter-in-Place Order because it falls within the following essential infrastructure sector (more details available here https://covid19.ca.gov/img/EssentialCriticalInfrastructureWorkers.pdf): *

Healthcare/Public Health

Emergency Services

Food and Agriculture

Energy

Water and Wastewater

Transportation and Logistics

Communications and Information Technology

Other Community based government operations and essential functions

Critical Manufacturing

Hazardous Materials

Financial Services

Chemical

Defense Industrial Base

Describe the procedures, practices, and/or protocols that employer has adopted and implemented to ensure that all employees and customers maintain 6-feet of distance from one another. *

Describe the procedures, practices, and/or protocols that employer has adopted and implemented to maximize hygiene (e.g., regularly wiping down surfaces, mandating hand-washing, making hand sanitizer available at stations throughout facility, etc.). *

What is the desired start date for the employee? *

YYYY

Employer Signature - By typing my name below, I verify that all of the information above is true and correct. I agree that my electronic signature below is the same as a handwritten signature for purposes of validity, enforceability, and admissibility. *

Send me a copy of my responses.

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