Meal Break Waiver

Meal Break Waiver

To be completed for every day a waiver is requested
Employee Name*

First NameLast Name
Employee Company Email Address*
example@example.com
Location you work*

ArizonaBakersfieldBNSF - LAInland EmpireOaklandOfframp - LAPortlandCorp Office
Date Waiver is Requested*

MonthDayYear
Date
In accordance with an applicable wage order of the California Industrial Welfare Commission and/or company policy, I am requesting a waiver of my right to an unpaid 30 minute meal break on a day when my work will be completed in 6 hours or less OR when my work exceeds 10 hours, but is not more than 12 hours, and I have not waived my first meal break.
Type of Wavier you are requesting*

Working no more than 6 hours, no 30 minute meal breakWorking more that 10 hours, but not more than 12, with no second 30 minute meal break
I understand that if I work more than 6 hours I must take an unpaid 30 minute meal break, after 4 hours of work and before 4.5 hours of work, per company policy and/or state law.*

YES
I understand that my 30 minute meal break can not be taken after 5 hours of work if working more than 6 hours, per company policy and/or state law.*

YES
You will receive an email response to your request letting you know if your request has been approved or denied. Please print or keep a copy of the email for your records.
Signature

Clear
Should be Empty: