Statement of Intent to Employ a Minor and Request for a Work Permit - Certificate of Age (CDE Form B1-1) - Student Section [ARISE H.S.]
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 Home or Cell Phone *
Student's Grade *
Student's Home Street Address *
Student's Home City, State, Zip Code *
Student's Birth Date *
MM
/
DD
/
YYYY
Student's Social Security Number (###-##-####) or Individual Tax Identified Number (ITIN) *
Student's Age *
Student's School Name *
Student's School Phone Number *
Student's School Address *
Name of Employer (Company/Organization who has offered you a position) *
Student 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. *
A copy of your responses will be emailed to the address you provided.
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