State Of Licteri Division Of Labor Standards Enforcement

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STATE OF CALIFORNIA

Division of Labor Standards Enforcement

THIS IS NOT A PERMIT

NEW

RENEWAL

APPLICATION FOR PERMISSION TO WORK IN THE ENTERTAINMENT INDUSTRY
PROCEDURES FOR OBTAINING WORK PERMIT 1. Complete the information required below. 2. School authorities must complete the "School Record" section below. 3. For minors 15 days through kindergarten, please attach a certified copy of the minor's birth certificate. See reverse side for other documents that may be accepted. 4. Mail or present the completed application to any office of the Division of Labor Standards Enforcement for issuance of your work permit. Work permits will be issued within 3 business days and mailed to you. 5. Please provide a preaddressed, stamped envelope.
Name of Child Professional Name (if applicable)

Permanent Address
Number Street City State Zip Code

Home Phone Number

School Attending

Grade

Date of Birth

Age

Height

Weight

Hair Color

Eye Color

Gender Male Female

STATEMENT OF PARENT OR GUARDIAN: It is my desire that an Entertainment Work Permit be issued to the above named child. I will read the rules governing such employment and will cooperate to the best of my ability in safeguarding his or her educational, moral and physical interest. I hereby certify, under penalty of perjury, that the foregoing statements are true and correct.
Name of Parent or Guardian ( print or type) Signature Daytime Phone Number

SCHOOL RECORD
State whether “SATISFACTORY" or "UNSATISFACTORY" for each Attendance I CERTIFY THAT THE ABOVE-NAMED MINOR:
Meets the school district's requirements with respect to age, school record, attendance and health. Does not meet the district’s requirements and permit should not be issued.

Scholarship (Grades)

Health

Authorized School Official

Date

School Address

School Phone Number [School Seal]

HEALTH RECORD
Complete this Section if instructed to do so or if infant is under One Month of Age Name of Doctor Address Phone Number

I certify that I am a licensed physician and surgeon who is Board Certified in pediatrics, and have carefully examined _______________________. In my opinion, (please circle) he / she is / is not physically fit to be employed in the production of motion pictures and television. If less than one month, infant is / is not at least 15 days old, was / was not carried to full term, and is / is not physically able to perform. Signature Remarks: M. D. Date

DLSE-277 (Rev. 12/03)

Information covering California's child labor laws applicable to the entertainment industry can be found at www.dir.ca.gov/dlse/dlse.html

PROCEDURE FOR OBTAINING AN “ENTERTAINMENT PERMIT”
NEW Obtain from any of the Division of Labor Standards offices. Complete all requested information on the front of the application. Please print and sign your name. 3.) School Record Information To be completely filled out by authorized school district official. 1.) Application Form 2.) Parent/Guardian
A PREADDRESSED, STAMPED ENVELOPE MUST ACCOMPANY THE APPLICATION

REQUIREMENTS FOR NON-SCHOOOL AGE CHILDREN 1.) 2.) 3.) 4.)

ONE OF THE FOLLOWING:

Certified Birth Certificate Baptismal
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