Change of Work Hours Request
Summer 2017 Flexible Work Hours
TO: __________________________
Immediate Supervisor
FROM: __________________________
Employee
DATE: __________________________
I would like to request flexible work hours and change my work schedule for the specified period of time
indicated below.
If approved, my work schedule would be:
Work Days: ___________________________________
Work Hours: ___________________________________
All schedules begin Sunday, May 28th and end on Saturday, August 19th, 2017
I understand that if I am a non-exempt (hourly) employee the hours I work in excess of eight
(8) hours each day will be paid at my regular pay rate, not at an overtime pay rate. However,
any approved hours I may work in excess of forty (40) hours each work week will be paid at the overtime
pay rate.
The signatures below indicates our agreement to change my work schedule with the full
understanding that should business conditions change during this time I may be required to
revert to my normal schedule with or without advance notice.
____________________________________ _________________________________
Employee/Date Supervisor/Date
Approved Not Approved
Human Resources review:
__________________________________
Vice President/Date ___________ _______
cc: Personnel File Initials Date