• Student Work Permit Application Form

• 
  
• Date
• Student Last Name, First Name*
• Student Birthdate*
• Student Address*

  Street Address 1

  Street Address 2

  City

  State/Province/Region

  Postal/Zip Code

  Country
• 
  
• School
• School Address

  Street Address 1

  Street Address 2

  City

  State/Province/Region

  Postal/Zip Code

  Country
• 
  
• Current Grade
• List the work schedule student wishes to work.*
• Student Schedule (Include Lunch Break)

  Period	Class	Teacher	Start-End Time
  1
  2
  3
  4
  5
  6
  7
  8

• 
  
• Student Counselor Last Name, First Name*
• Counselor Phone Number*

  --
• Counselor Signature and Date*
• Parent Last Name, First Name*
• Parent Phone*

  --
• Parent Signature and Date*
• Student Signature and Date*