Employers Group | Experts in Making Human Resources
Meal Waiver Form
SAMPLE MEAL PERIOD WAIVER FOR
WORKING SHIFTS IN EXCESS OF TEN HOURS *
This will certify that I regularly work a shift in excess of ten (10) but not more than twelve (12) hours and wish to waive the second meal period I would otherwise be entitled to receive under California law. In accordance with the requirements of state law, I hereby voluntarily agree to waive the second meal period each day. I understand that, as a result of this waiver, I will receive only one meal period during each day of work and will be paid for all working time, but not for the one duty-free meal period I receive. I also understand that I, or __(Company Name)__ may revoke this “Meal Period Waiver” at any time by providing at least one (1) day’s advance notice in writing of the decision to do so. This waiver will remain in effect until I exercise, or __(Company Name)__ exercises the option to revoke it.
I acknowledge that I have read this waiver, understand it, and voluntarily agree to its provisions.
_____________________________________ _______________
Signature of Employee Date
_____________________________________
Print or Type Name of Employee
APPROVED FOR ________________________
By: ____________________________________ _____________
---------------------------------------------------------------------------------------------------- *This meal period waiver applies if an employee works more than ten hours in a day; but not more than 12 hours.
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