Statement of Intent to Employ a Minor and Request for a Work Permit - Certificate of Age (CDE Form B1-1) - Parent/Guardian 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.
Student's Last Name *
Student's First Name *
Parent/Guardian's Home or Cell Phone *
Student's Grade *
Student's Home Address *
Student's Birth Date *
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DD
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Student's Social Security Number (###-##-####) or Individual Taxpayer Identification Number (ITIN) *
Student's Age *
Student's School Name *
Parent/Guardian First and Last Name *
Parent/Guardian Email Address *
Parent/Guardian Signature - By typing my name below, I verify that my child 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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