TIME CLOCK CHANGE REQUEST FORM

***Please note: Incomplete forms will be returned***

Employee’s name: ________________________________

Date to be changed: ________________________________

Clock in time: ________________________________ ____a.m. ____p.m.

(The time you should have clocked in)

Clock out time: ________________________________ ____a.m. ____p.m.

(The time you should have clocked out)

Reason for change request:

Clock was not working ______

Forgot ______

Other ____________________________________

_________________________________________________

_________________________________________________

_________________________________________________

__________________________ _______________________________________________

Date Employee Signature

__________________________ _______________________________________________

Date Principal / Supervisor Signature

__________________________ ________________________________________________

Date Completed Change Administrator Signature