Statement of Intent to Employ a Minor and Request for a Work Permit - Certificate of Age (CDE Form B1-1) - Non-OUSD Principal
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.
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Email *
Student's Last Name *
Student's First Name *
Student's Grade *
Student's School *
Principal's Phone Number *
Student's School Address *
Student's GPA is 2.0 or higher. *
Student's attendance is 90% or higher. *
If the answer to either of the two previous questions is "no," but you would like to provide any additional context or to be contacted by OUSD to explore the possibility of setting up an intervention to allow for a provisional permit, please explain below.
Principal Signature - By typing my name below, I verify that the student listed on this form is being employed with my full knowledge and consent, and that 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. *
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