Flexible Work Hour Plan Form - Division Of Labor Standards & Safety

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DIVISION of
LABOR STANDARDS & SAFETY
Wage and Hour Administration
(Addresses for regional offices on page 2)
FLEXIBLE WORK HOUR PLAN
EMPLOYER NAME OR DBA:
DATE:
(PLEASE PRINT)
AUTHORIZED REPRESENTATIVE:
PHONE:
FAX:
(PLEASE PRINT)
(
)
(
)
ADDRESS:
CITY:
STATE:
ZIP:
I understand that the regulation 8 AAC 15.102 (on back of this form) and the following
conditions apply to all flexible work hour plans:
1. This exemption is designed to provide employers some relief from overtime. In exchange,
have the opportunity to work a full 40 hour workweek in a reduced number of days.
2. Flex-plans are not intended to allow an employer to routinely schedule employees to work
more than 40 hours per week.
3. Employee participation in this plan must be voluntary and cannot be a condition of employment.
4. An employee who works more than the daily/weekly hours specified in the plan as described
below, must be paid overtime for the extra hours.
5. Failure to follow an approved plan creates an overtime liability for hours worked over 8 in a day and/or
40 straight time hours in a week. For example, an employee who regularly works more
or less hours than outlined in the plan is due overtime for hours worked over 8 in a day and/or
40 straight time hours in a workweek.
6. Employers must keep copies of the approved plan on file signed and dated by each participating
employee.
7. Plans are approved for a specific employer and may not be transferred to another employer.
8. NOTE: Variation from an approved plan may void the plan entirely.
THE FOLLOWING IS A DESCRIPTION OF THE EMPLOYER'S WORK SCHEDULE:
PLEASE NOTE: By signing, the employer acknowledges and accepts the conditions listed above.
EMPLOYER'S AUTHORIZED SIGNATURE:
TITLE:
**STATE USE ONLY**
DATE APPROVED: _______________
AUTHORIZED REPRESENTATIVE
DATE DISAPPROVED:_______________
***TO BE SIGNED BY EMPLOYEE AFTER DEPARTMENT APPROVAL*****
**Employee participation must be voluntary and uncoerced**
EMPLOYEE NAME
:
(PLEASE PRINT)
EMPLOYEE SIGNATURE:
DATE:
Jobs are Alaska's Future
Revised: 07/09

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