Transcription of Application for Work Permit
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Application for Work Permit
APPLICATIONFORWORKPERMITD ateof application_____Certificate/Permitnumber _____PDE 4565(1/13) minorSex_____Colorof 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 . Application FOR WORK Permit Date of Application _____ Certificate/ Permit number _____ PDE 4565 (1/13) Date issued _____ A.
Commonwealthof Pennsylvania ‐Department of Education *In lieu ofsignature under clause(B),the applicant mayexecute a statement before a notary public orother person authorizedto administeroathsattesting to the accuracyofthe factsset forthin the application ona form prescribed by the department. The statement shall be attached to the application.
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