Ny Notice Form – Fill Out and Use This PDF

Please fill in Sections 2, 3, and 8. Sign and Date.

1.Employer Information

Name: Barnard College

Physical Address:

117th Street and Broadway New York, New York 10027

Mailing Address:

3009 Broadway

New York, New York 10027 Phone: 212-854-2033

2.Notice Given:

At hiring

On or before February 1

Before a change in pay rate(s), allowances claimed or payday

Notice and Acknowledgement of Pay Rate and Payday Under Section 195.1 of the New York State Labor Law

Notice for Hourly Rate Employees

3.Employee’s rate s of pay for each type of work or shift:

__________ for _______________________

Hourly RateJob Title

__________ for _______________________

Hourly RateJob Title

__________ for _______________________

Hourly Rate

Job Title

4. Allowances taken:

None

 Tips __ per hour  Meals __ per meal  Lodging ______

 Other __________________

5. Regular payday: Friday

6. Pay is: Bi-weekly

7. Overtime Pay Rate(s) for each type of

work or shift: N/A times the worker’s weighted This must be at least 1½

average of the multiple rates of pay for the week, with few exceptions. The weighted average is the total regular pay divided by the total hours worked in the week. The overtime rate may vary from week to week depending on how many hours you worked at each rate of pay. The overtime rate may vary from week to week.

8.Employee Acknowledgement:

On this day I have been notified of my pay rate, overtime rate (if eligible), allowances, and designated payday on the date given below. I told my employer what my primary language is.

Check one:

I have been given this pay notice in English because it is my primary language.

My primary language is ________________________. I have been given this pay notice in English only, because the Department of Labor does not yet offer a pay notice form in my primary language.

Print Employee Name

Employee Signature

Date

Won Kang

Associate Director for Student Employment_______

Preparer Name and Title

The employee must receive a signed copy of this form. The employer must keep the original for 6 years.

Please return the original to Career Development (2nd Floor of Elliott Hall) immediately. Copies can be made for you at the office. Thank you.