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Get CA Meal Period & Rest Break Premium Request Form

Tted to take third rest break on ___________1 ____________________________________ Employee (print first/last name) ________________ Date Employee ID No. __________________ Submit completed form to Supervisor by the end of the pay period To be completed by supervisor: ____________________________________ Supervisor _________________ Date Supervisor ID No. _________________ Submit form to Payroll Department by the end of the pay period 1 Another box should be added for a fourth rest bre.

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