Meal Break Waiver Form

Meal Break Waiver Form
INFORMATION
In accordance with California’s Industrial Welfare Commission Order No. 4-2001, Section 11, an employee
working more than five (5) hours in a workday must take an unpaid meal break of at least 30 minutes. However,
the meal break may be waived by mutual consent of the employee and employer if the workday does not exceed
six (6) hours.
If you wish to waive your 30-minute unpaid meal break, please forward the completed waiver to the PAVIR
office with your timesheet for the effective pay period. The waiver will be in effect until the employee decides to
revoke the agreement.
WAIVER
In accordance with California’s Industrial Welfare Commission Order No. 4-2001, Section 11, I am requesting a
waiver of my right to an unpaid 30-minute meal break when my workday will be completed in six (6) hours or
less.
I understand that:
1. I may waive my 30-minute unpaid meal break only when my workday will be completed in six (6) hours
or less.
2. In order for this waiver to be valid, a representative from the HR/Payroll department must also authorize
the waiver in writing by signing below.
3. I may revoke this agreement to waive my meal break at any time by signing this form as indicated below.
4. This waiver will be maintained with my timesheets in the PAVIR office.
EMPLOYEE CONSENT:
_____________________________________
Employee’s Name (Print)
_____________________________________
Employee’s Signature
____________________
Effective Date
REVOCATION: I hereby revoke this waiver.
_____________________________________
____________________
Employee’s Signature
Date
PAVIR Use Only