ScHEDULE ForM 
DEPARTMENT OF LABOR AND INDUSTRY 
COMMONWEALTH OF PENNSYLVANIA 
Sex. ..... 
Establishment No....... Scheduled weekly hours...... Shift...... 
Name 
or 
a0. 
Actual earnings 
Two | 
weeks or 
Depart- semi- i 
ment ‘monthly 
Weekly 
Actual! hours 
Two 
#eeks or 
semi- 
nonthly 
Weekly 
Hours 
over- 
-ime 
Hours Btatus 
under- | of 
time hours 
Annual 
sarnings 
1627