Notice To Employee Template printable pdf download

Notice To Employee Template

NOTICE TO EMPLOYEE

Labor Code section 2810.5

EMPLOYEE

Employee Name:

Start Date:

EMPLOYER

Legal Name of Hiring Employer:

Is hiring employer a staffing agency/business (e.g., Temporary Services Agency; Employee Leasing

Company; or Professional Employer Organization [PEO])? □ Yes

□ No

Other Names Hiring Employer is "doing business as" (if applicable):

Physical Address of Hiring Employer’s Main Office:

Hiring Employer’s Mailing Address (if different than above):

Hiring Employer’s Telephone Number:

If the hiring employer is a staffing agency/business (above box checked "Yes"), the following is the other entity

for whom this employee will perform work:

Name:

Physical Address of Main Office:

Mailing Address:

Telephone Number:

WAGE INFORMATION

Rate(s) of Pay:

Overtime Rate(s) of Pay:

Rate by (check box):

□ Hour

□ Shift

□ Day

□ Week

□ Salary

□ Piece rate

□ Commission

□ Other (provide specifics):

(check box)

□ Yes

□ No

Does a written agreement exist providing the rate(s) of pay?

If yes, are all rate(s) of pay and bases thereof contained in that written agreement?

□ Yes

□ No

Allowances, if any, claimed as part of minimum wage (including meal or lodging allowances):

(If the employee has signed the acknowledgment of receipt below, it does not constitute a “voluntary written

agreement” as required under the law between the employer and employee in order to credit any meals or lodging

against the minimum wage. Any such voluntary written agreement must be evidenced by a separate document.)

Regular Payday:

DLSE-NTE (rev 9/2014)

Notice To Employee Template

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