Employee Pay Rate Acknowledgement

EMPLOYEE PAY RATE ACKNOWLEDGEMENT

Employee Name:   Employee ID:

Personal Information

Position Information

Job Title:   Department:

Reporting Manager:   Start Date:

Full-time   Part-time   Temporary   Contract

Exempt Status:   Exempt   Non-exempt

Pay Type:   Salary   Hourly   Commission

Pay Details

Effective Pay Rate:   Pay Period:

Regular Hours Per Pay Period:   Overtime Rate (if applicable):

Direct Deposit   Check   Pay Card

Payroll Withholdings and Deductions

I acknowledge that the employer will withhold federal, state and local taxes and make deductions required by law (including garnishments, child support or tax levies) and authorized deductions for benefits and other elected programs. The employer will provide itemized pay statements in accordance with applicable law. Deductions will be taken in accordance with written elections, company policies and applicable statutes.

If classified as non-exempt, overtime compensation will be paid in accordance with applicable law for hours worked in excess of the statutory threshold. If classified as exempt, the employee understands that the stated salary is intended to meet the duties and salary basis tests for exemption and that job duties, not title alone, determine exemption classification.

Change in Compensation

The employer reserves the right to change compensation, benefits, and pay schedule at its discretion, subject to applicable law. Any change to the employee's rate of pay will be communicated in writing and will specify an effective date. Retroactive adjustments may be made only when required or authorized by the employer in writing.

Acknowledgement and Certification

I certify that I have received and reviewed the above pay rate and employment classification information. I understand and agree that this acknowledgement is documentation of my current rate of pay and classification only and does not constitute an employment contract or guarantee of future compensation, hours, or continued employment. My employment, if not governed by a separate written agreement, is at-will and may be terminated by either party at any time, with or without cause, as permitted by law.

I understand my responsibility to report errors in pay, overtime, or deductions promptly. I agree to notify the Human Resources department if any payroll or benefit elections require amendment.

Employment History

Title:   Dates Employed: From to

Title:   Dates Employed: From to

Education

Professional References

Phone:   Email:   Relationship:

Phone:   Email:   Relationship:

Phone:   Email:   Relationship:

Equal Employment Opportunity

The employer is an equal opportunity employer. Employment decisions are based on business needs, job requirements and individual qualifications, without regard to race, color, religion, sex, national origin, age, disability, genetic information, marital status or any other protected characteristic under applicable law.

Authorization

By checking the box below and signing this form, I authorize the employer to verify the information provided in this document, to contact previous employers and listed references, and to obtain consumer reports, background checks, and employment verification as permitted by law. I understand that consent may be withdrawn in writing, but that withdrawal may affect my eligibility for employment or certain benefits.

I consent to verification and background checks as described above.

Applicant Certification

I certify that the information contained in this form is true and complete to the best of my knowledge. I understand that providing false or misleading information may result in disciplinary action, up to and including termination. I acknowledge receipt of the pay rate information documented above and accept the terms described herein.

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