Break Waiver Form

Employee Name: ____Lucky Ly__________ ID Number:

___________
(print name)

Waiver Effective Date: __9/11/2016_________

I understand that under California Labor Law, after a work period
of 4 hours or more, I am entitled to receive a 10 min break which I
am relieved of all duties.
I give my consent that I may waive my 10-minute break only when
my work and/or scheduled shift.
In order for this waiver to be valid, my supervisor must also
authorize the waiver in writing by signing below.
I understand that I may revoke this agreement to waive this meal
break in writing at any time by signing this form and notifying my
supervisor.
Employee Authorization

X
Employee Signature: _____
_____________ Date: _____________
Supervisor Authorization
Supervisor Signature: __________________Date: _____________