Employee Certification of Hours Worked and Meal & Rest Periods

Name: {field_5}

Manager: {field_22}

Date: {field_30}

Start Time: {field_31}

End Time: {field_32}

Regarding hours worked, EITHER: {field_9}

Regarding meal periods, EITHER: {field_11}

Please explain what adjustment is needed. If you are requesting a meal or rest break premium, please include the reason you were unable to take your break on time or why the break was missed. {field_26}

Regarding rest periods, EITHER: {field_15}

Employee Signature:
{field_6}

Select All That Apply: {field_20}