Transcription of Application for Work Permit
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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 th
APPLICATIONFORWORKPERMIT Dateofapplication _____ Certificate/Permit number _____ PDE‐4565(1/13) Dateissued _____ A. To becompletedbyissuing officer Name ofminor Sex
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