Prevailing Wage Notice Form

Prevailing Wage Notice Form
Please review and acknowledge the details of your prevailing wage assignment.
Employee Full Name
First NameLast Name
Employer/Company Name
Project Name or Number
Project Location (Address)
Street Address
Street Address Line 2
CityState / ProvincePostal / Zip Code
Job Title / Classification
Wage Rate per Hour (USD)
Overtime Rate per Hour (USD)
Work Schedule (Days/Hours per Week)
Start Date of Assignment
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Expected End Date
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Are fringe benefits provided?
Additional Comments or Notes
Employee Signature (Acknowledgment of Receipt)
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