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
seminonthly


Weekly

Hours
over--ime


Hours Btatus
under- | of
time hours

Annual
sarnings
1627