Form Dlse -277 - Application For Permission To Work In The Entertainment Industry -

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THIS IS NOT A PERMIT

STATE OF CALIFORNIA

Division of Labor Standards Enforcement

NEW (never applied before)

RENEW

Permit No. ______________

APPLICATION FOR PERMISSION TO WORK IN THE ENTERTAINMENT INDUSTRY

PROCEDURES FOR OBTAINING WORK PERMIT

Complete the information required below.

School authorities must complete the “School Record” section below for minors in grades 1 thru 12.

For minors 15 days through kindergarten, please attach a photo copy of minor’s birth certificate. See reverse side for other documents

that may be accepted.

All signatures MUST be in original ink. No fax or photo copies permitted.

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.

Please provide a preaddressed, stamped envelope so the permit can be mailed back to you.

Name of Child

Professional Name (if applicable)

AKA:

Permanent Address

Home Phone Number

Number

Street

City

State

Zip Code

School Attending

Grade

Date of Birth

Age

Height

Weight

Hair Color

Eye Color

Gender

‘

“

Male

ft.

in.

lbs.

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.

By submitting personal information about yourself and your minor child to DLSE in order to obtain an entertainment work permit for your child, you consent to

DLSE’s use of that personal information for purposes authorized by Labor Code § 1308.5 and 1308.10, which provide for the issuance of such permits. Note that

DLSE’s use of such personal information includes the disclosure of information about you and your minor child to third parties who want to verify a work permit.

Name of Parent or Guardian (print or type)

Signature

Daytime Phone Number

SCHOOL RECORD

Circle whether “SATISFACTORY” or “UNSATISFACTORY” for each

Attendance

Academics (Grades)

Health – Please indicate if the minor requires

medical approval to obtain a permit

SATISFACTORY / UNSATISFACTORY

SATISFACTORY / NEEDS MEDICAL APPROVAL

I CERTIFY THAT THE ABOVE-NAMED MINOR: