EMPLOYEE NAME:*

TIME PERIOD:*

DEPARTMENT:___DPW__

LOCATION:*

DRIVER:*

1.

17.

2.

18.

3.

19.

4.

20.

5.

21.

6.

22.

7.

23.

8.

24.

9.

25.

10.

26.

11.

27.

12.

28.

13.

29.

14.

30.

15.

31.

16.

TOTAL HOURS:*

@

$

BY CHECKING THIS BOX I HEREBY CERTIFY THAT I HAVE WORKED OR WILL WORK THE HOURS INDICATED. IN THE EVENT I DO NOT WORK THE HOURS INDICATED ABOVE, I AUTHORIZE THE BOROUGH CLERK TO MAKE THE NECESSARY ADJUSTMENTS IN MY SALARY.

PLEASE CHECK AGREE AND ENTER YOUR NAME FOR SIGNATURE.
(By typing in your name you are signing this form.)

AGREE

EMPLOYEE SIGNATURE:*

ALL HOURS ARE CONTINGINT ON YOUR DEPARTMENT HEAD'S APPROVAL AFTER SUBMITTING THE FORM.