Application for Work Permit
APPLICATION FOR WORK PERMIT
PDE-4565 (1/13)
Date of application ______________________________________ Certificate/Permit number ________________________________ Date issued _____________________________________________
A. To be completed by the applicant Name of minor
Any physical work restrictions
Sex_____________________________ Color of hair _____________________ Color of eyes ____________________
Signature of issuing officer
School district - name and address
Place of residence
Place of birth
Date of birth Month Day Year
Evidence of age accepted and filed. Evidence shall be required in the order designated. Check the accepted evidence.
a. Transcript of birth certificate
b. Baptismal certificate or transcript
c. Passport
d. Other documentary evidence
e. Affidavit of parent or guardian accompanied by
physician's statement of opinion as to the age of the minor
B. To be completed by parent or guardian, unless minor is a high school graduate (please attach proof of graduation)
Signature of parent, guardian or legal custodian*
Name and address of parent, guardian or legal custodian
Commonwealth of Pennsylvania - Department of Education
*In lieu of signature under clause (B), the applicant may execute a statement before a notary public or other person authorized to administer oaths attesting to the accuracy of the facts set forth in the application on a form prescribed by the department. The statement shall be attached to the application.
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