ࡱ> c hbjbj ;WbWbb b 8*G44 DQ FFFFFFF$gILGu  GwG%%% FF% F%%d?@Ъ!#;!v0@FG0GJ@M!M4@M@ % GG#  G M b B : STATE OF CALIFORNIA DEPARTMENT OF EDUCATION STATEMENT OF INTENT TO EMPLOY A MINOR AND REQUEST FOR A WORK PERMITCERTIFICATE OF AGE CDE Form B1-1 (Rev. 02-14) A Statement of Intent to Employ A Minor and Request for A Work PermitCertificate of Age form (CDE Form B1-1) shall be completed in accordance with California Education Code 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. (Print Information) Minors Information FORMTEXT       FORMTEXT       FORMTEXT      Minor s Name (First and Last)Home PhoneGrade FORMTEXT       FORMTEXT       FORMTEXT      Home AddressCityZip Code  FORMTEXT       FORMTEXT       FORMTEXT       Birth DateSocial Security Number AgeStudent s SignatureSchool Information FORMTEXT       FORMTEXT      School NameSchool Phone FORMTEXT       FORMTEXT       FORMTEXT      School AddressCityZip CodeTo be filled in and signed by parent or legal guardianThis minor is being employed at the place of work described with my full knowledge and consent. I hereby certify that to the best of my knowledge and belief, the information herein is correct and true.  FORMTEXT      Parent s Name (Print First and Last)Parent s SignatureDate To be filled in and signed by employer FORMTEXT       FORMTEXT       FORMTEXT      Business Name or Agency of PlacementBusiness PhoneSupervisor s Name FORMTEXT       FORMTEXT       FORMTEXT      Business Address CityZip CodeEmployer s Maximum Expected Work Hours: _________ hours per day ________ hours per weekDescribe nature of work to be performed: FORMTEXT       FORMTEXT      In compliance with California labor laws, this employee is covered by workers compensation insurance. This business does not discriminate unlawfully on the basis of race, ethnic background, religion, sex, sexual orientation, color, national origin, ancestry, age, physical handicap, or medical condition. I hereby certify that, to the best of my knowledge, the information herein is correct and true.  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