NOTICE TO EMPLOYEE 
                                              Labor Code section 2810.5 

                                                   EMPLOYEE 

Employee Name: 
Start Date:  

                                                   EMPLOYER 

Legal Name of Hiring Employer: 
Is hiring employer a staffing agency/business (e.g., Temporary Services Agency; Employee Leasing Company; or 
                            Professional Employer Organization [PEO])?      □ Yes                    □ No 
Other Names Hiring Employer is "doing business as" (if applicable): 

Physical Address of Hiring Employer’s Main Office: 

Hiring Employer’s Mailing Address (if different than above): 

Hiring Employer’s Telephone Number: 

If the hiring employer is a staffing agency/business (above box checked "Yes"), the following is the other entity for whom this 
employee will perform work: 
Name:  
Physical Address of Main Office: 
Mailing Address:  
Telephone Number:  

                                       WAGE INFORMATION 

Rate(s) of Pay:                                    Overtime Rate(s) of Pay: 
Rate by (check box): □ Hour    □ Shift □ Day                 □ Week     □ Salary      □ Piece rate   □ Commission
□ Other (provide specifics):
Does a written agreement exist providing the rate(s) of pay?        (check box)   □ Yes     □      No
If yes, are all rate(s) of pay and bases thereof contained in that written agreement?              □ Yes  □ No
Allowances, if any, claimed as part of minimum wage (including meal or lodging allowances): 

(If the employee has signed the acknowledgment of receipt below, it does not constitute a “voluntary written agreement” as 
required under the law between the employer and employee in order to credit any meals or lodging against the minimum wage.  Any 
such voluntary written agreement must be evidenced by a separate document.) 

Regular Payday: 

DLSE-NTE (rev 11/2023) 

                                       WORKERS’ COMPENSATION 

Insurance Carrier’s Name: 
Address:   
Telephone Number:   
Policy No.:   
□ Self-Insured (Labor Code 3700) and Certificate Number for Consent to Self-Insure:

                                            PAID SICK LEAVE 
Unless exempt, the employee identified on this notice is entitled to minimum requirements for paid sick leave under state 
law which provides that an employee: 
       a.  May accrue paid sick leave and may request and use up to 5 days or 40 hours, whichever is greater, of 
           accrued paid sick leave per year;
       b.  May not be terminated or retaliated against for using or requesting the use of paid sick leave; and
       c.  Has the right to file a complaint against an employer who retaliates or discriminates against an employee for
           1. requesting or using sick days;
           2. attempting to exercise the right to use paid sick days;
           3. filing a complaint or alleging a violation of Article 1.5 section 245 et seq. of the California Labor Code;
           4. cooperating in an investigation or prosecution of an alleged violation of this Article or opposing any 
              policy or practice or act that is prohibited by Article 1.5 section 245 et seq. of the California Labor
The following applies to the employee identified on this notice: (Check one box) 
□ 1.  Accrues paid sick leave only pursuant to the minimum requirements stated in Labor Code §245 et seq. with no
  other employer policy providing additional or different terms for accrual and use of paid sick leave. 
□ 2.  Accrues paid sick leave pursuant to the employer’s policy which satisfies or exceeds the accrual, carryover, and use
  requirements of Labor Code §246. 
□ 3.  Employer provides no less than 40 hours (or 5 days) of paid sick leave at the beginning of each 12-month period.
□ 4.  The employee is exempt or partially exempt from paid sick leave by Labor Code §245.5. (State exemption and
  subsection for exemption): 
                              EMERGENCY OR DISASTER DISCLOSURE 
□ There is a state or federal emergency or disaster declaration applicable to the county or counties where the employee
will work issued within 30 days before the employee’s first day of employment and that may affect their health and safety
during employment. (State emergency or disaster declaration and how it may affect health or safety)
______________________________________________________________________________________________
______________________________________________________________________________________________

                                  ACKNOWLEDGEMENT OF RECEIPT 

(PRINT NAME of Employer representative)                              (PRINT NAME of Employee) 

(SIGNATURE of Employer Representative)                               (SIGNATURE of Employee) 

(Date)                                                               (Date) 
The employee’s signature on this notice merely constitutes acknowledgement of receipt. 

Labor Code section 2810.5(b) requires that the employer notify you in writing of any changes to the information set 
forth in this Notice within seven calendar days after the time of the changes, unless one of the following applies:  (a) 
All changes are reflected on a timely wage statement furnished in accordance with Labor Code section 226; (b) Notice 
of all changes is provided in another writing required by law within seven days of the changes. 

  DLSE-NTE (rev 11/2023)