Back Pay Request Form
Employee's name
*
First Name
Last Name
Employee's Email
*
example@example.com
Supervisor's name
*
First Name
Last Name
Reason for back pay request
*
Employee paid wrong wage rate
Employee forgot to clock in
Supervisor Error
Dates and Times of Hours Actually Worked
*
Attach time sheet (if applicable)
Browse Files
Cancel
of
Total number of back pay hours needed
*
Total $ amount of back pay needed
*
Reason for check request
Notes
Signature
*
Submit
Should be Empty: