NOTICE OF HIRE – EMPLOYMENT STATUS
AND ACKNOWLEDGEMENT OF WAGE RATE(S)
□ At Hire □ Current Employee □ Annual–Current Date__________ □ Change in pay rate(s) or payday
Effective Date: _____/____/______
Notice of Hire (Check only one)
Company Name: _________________________________
DBA: ___________________________________
Permanent Address: ________________________________
Street Line 2:___________________________________
City: ___________________ State: ______
Zip Code: _______________
Mailing Address: □ Same as Physical Address
_______________________________________________
Street Line 2:____________________________________
City: ________ State: _______ Zip Code: ___________
Phone: (_____) _________-_______________
Employee Name: _________________________________
Physical Address: ________________________________
City: ___________________ State: _____
Zip Code: _______________
Mailing Address: □ Same as Physical Address
_______________________________________________
Street Line 2:____________________________________
City: ________ State: _______ Zip Code: ___________
Phone: (_____) _________-_______________
Employee
Employer
Pay Frequency and Payday
Pay Frequency: __________________________ Designated Pay Day: ______________________
(Weekly, bi-weekly, semi-monthly, monthly, etc.) (Day of week when wages are payable/available)
□ Tips $_____________ per hour
□ Meals $_____________ per meal
□ Lodging $_____________ per _______________
□ Other $_____________ per _______________
As of January 1, 2005, the minimum wage required to be paid by any employer in the District of Columbia to any employee who
receives gratuities shall be $2.77 an hour, provided that the employee actually receives gratuities in an amount at least equal to the
difference between the hourly wage paid and the minimum wage. Also, all gratuities received by the employee must be retained by
the employee. This employee (will or will not) participate in the following company tip pool:
Tip Pool Policy: (Explain if applicable)
Allowances Claimed As Part of Wages: □ None, or:
Tipped Employees
Section 1
Section 2
Section 3
Section 4
Basis of Wage Payment
Pay Basis: _______________________ (hourly, shift, day, week, salary, piece, commission)
Rate of Pay: _________ per hour
Overtime Rate of Pay*_______ per hour
□ Overtime Pay Exemption for bona fide
□ Administrative
□ Executive
□ Professional
□ Hourly
Rate of Pay: _________ per ______________ Overtime Rate: _________
Rate of Pay: _________ per ______________ Overtime Rate: _________
Rate of Pay: _________ per ______________ Overtime Rate: _________
*No employer shall employ any employee for a workweek that is longer than 40
hours, unless the employee receives compensation for employment in excess of
40 hours at a rate not less than 1 ½ times the regular rate at which the
employee is employed.
□ Multiple Rates or Basis (for each type of basis)
□ Minimum Wage □ Living Wage □ Living Wage Exempt □ Employer Determined Wage Rate
Prevailing Rate Jobs: Your rate of pay will be the posted rate for the classification(s) listed.
Classification 1: _______________________________________ Prevailing Rate: _____________________________
Classification 2: _______________________________________ Prevailing Rate: _____________________________
Classification 3: _______________________________________ Prevailing Rate: _____________________________
□ Prevailing Rate (if Applicable)
Section 7
Section 6
Section 5
Section 8
The Department of Employment Services, specifically the Office of Wage-Hour (OWH), is to be contacted as that office is
the designated enforcement agency for the concerns about safety, wage and hour, or discrimination. The OWH can be
contacted at 202-671-1880 or via e-mail at owh.ask@dc.gov . The office is located at 4058 Minnesota Avenue, NE, Suite
4300 Washington, D.C. 20019. The office is open Monday –Thursday 8:30-4:30 and Friday 9:30-4:30.
Employee Acknowledgement: By signing below, I acknowledge that I have received the foregoing information regarding my pay
and my Employer. I told my employer what my primary language is:
Check one:
English
□ I have been given this pay notice in English.
Other Language
□ ______________. I have been given this pay notice in English only, because Office of Wage-Hour does not yet offer a pay notice
form in my primary language.
Employee’s Signature: _____________________________________ Date____/____/_____
Employer’s Signature: _____________________________________ Date____/____/_____
The Department of Employment Services provides templates for several common types of pay
agreements, including dual language notices and acknowledgements in English and Spanish. If
any other languages are needed, please contact the Office of Wage-Hour at 202-671-1880.
Employers may create their notices, use or adapt the notice provided by The Department of
Employment Services, as long as:
The required information appears in English and the employee’s primary language
The employee receives a copy
The employee signs an acknowledgment of receipt and identifies their primary language
to the employer
The employer keeps a copy of the notice and acknowledgement form
The Instructional Guide of how to complete this notice is found below:
Instructional Guide
Notice Given
Indicate the reason the form is being provided to the employee.
Section 1
Employer and Employee
Complete all fields.
Section 2
Pay Frequency and Pay Day
Indicate the frequency (e.g., weekly, bi-weekly, etc.) for when regularly scheduled wage payments will
be paid and also indicate the specific payday.
Section 3
Allowances Claimed as Part of Wages
Indicate any allowances claimed as part of the minimum wage, including tips, meals, and/or lodging
allowances.
Section 4
Tipped Employees
This section provides tipped employees the required notice under § 32-1003(f).
Note: Employers should also provide the company’s tip pool policy in this section or as an attachment.
Section 5
Basis of Wage Payment
Employer must specify whether the employee is paid minimum wage, living wage (or living wage
exempt), or if the wage rate is an employer-determined rate above minimum wage.
Specify the basis as hour, shift, day, week, salary, piece, and/or commission.
Provide the actual rate for each type of basis the employee will be paid.
Note: Employers must also provide employees with their overtime rate for each basis paid or given
notice that they are exempt from overtime. (Specify the reason for the exemption is for bona fide
Administrative, Executive, or Professional)
Section 6
Employees Paid Based on Prevailing Rates or other Jobs.
Complete this section when the employee will be paid a prevailing wage rate such as those specified
under the Davis Bacon Act or the Service Contract Act.
Employers must specify the classification(s) the employee will work and the related Wage Rate and any
Fringe Benefit applicable. Also, explain any overtime rates that will be paid for the work performed over
40 hours in a work week under each prevailing rate.
Section 7
According to WTPAA, information about how to contact the designated enforcement agency for
concerns about safety, wage and hour, or discrimination is to be on this notice.
Section 8
Employee Acknowledgement
The employee must acknowledge that he/she has disclosed his/her primary language by checking one of
the two boxes and that the employee has received the form by signing and dating the form.
Note: Employees have a right to receive this notice in a language other than English but only for those
languages for which the DOES Office of Wage-Hour has developed its own dual-language notice. Notices
will be available from Office of Wage-Hour in English and Spanish. If you need the forms translated in
other languages, please contact our office at 202-671-1880.
If an employee refuses to sign the notice, an employer should still give the notice to the employee and
note the employee’s refusal on its copy of the notice.
