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Application for Work Permit

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APPLICATIONFORWORKPERMITDateof application_____________________________ _________Certificate/Permitnumber_______ _________________________PDE 4565(1/13) minorSex_____________________________Col orof hair _____________________Colorof eyes____________________Signatureof issuingofficerAny physicalworkrestrictionsSchooldistrict nameand addressPlaceof residencePlaceof birthDateof birthEvidenceof age acceptedand requiredin the all but the one Transcriptof transcriptc. Passportd. parentor guardianaccompaniedbyphysician'sstatemen tof opinionas to theage of the minorMonth Day ,unlessminoris a highschoolgraduate(pleaseattachproofofgr aduation)Signatureof parent,guardianor legalcustodian*Nameand addressof parent,guardianor legalcustodianCommonwealthof Pennsylvania Departmentof Education*In lieu of signatureunderclause(B), the applicantmay executea statementbeforea notarypublicor otherpersonauthorizedtoadministeroathsat testingto the accuracyof the factsset forthin the applicationon a formprescribedby the attachedto the Application .

APPLICATIONFORWORKPERMIT Dateofapplication _____ Certificate/Permit number _____ PDE‐4565(1/13) Dateissued _____ A. To becompletedbyissuing officer Name ofminor Sex

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