Employee First Name:

Employee Last Name:

Email:

Calendar Month This Request Applies:--None--January February March April May June July August October November December

Date 1 You Worked

Date You Worked:

Work Start Time:

Work End Time:

Specific Class Name:

Club Name:--None--ARDEN CARMICHAEL CITRUS HEIGHTS DOWNTOWN ELK GROVE FOLSOM GREENHAVEN LAGUNA MADISON MIDTOWN NATOMAS ORANGEVALE POCKET ROCKLIN ROSEVILLE SPORTS COMPLEX SUNRISE WATT

Date 2 You Worked

Date You Worked:

Work Start Time:

Work End Time:

Specific Class Name:

Club Name:--None--ARDEN CARMICHAEL CITRUS HEIGHTS DOWNTOWN ELK GROVE FOLSOM GREENHAVEN LAGUNA MADISON MIDTOWN NATOMAS ORANGEVALE POCKET ROCKLIN ROSEVILLE SPORTS COMPLEX SUNRISE WATT

Date 2 You Worked

Date You Worked:

Work Start Time:

Work End Time:

Specific Class Name:

Club Name:--None--ARDEN CARMICHAEL CITRUS HEIGHTS DOWNTOWN ELK GROVE FOLSOM GREENHAVEN LAGUNA MADISON MIDTOWN NATOMAS ORANGEVALE POCKET ROCKLIN ROSEVILLE SPORTS COMPLEX SUNRISE WATT

Date 4 You Worked

Date You Worked:

Work Start Time:

Work End Time:

Specific Class Name:

Club Name:--None--ARDEN CARMICHAEL CITRUS HEIGHTS DOWNTOWN ELK GROVE FOLSOM GREENHAVEN LAGUNA MADISON MIDTOWN NATOMAS ORANGEVALE POCKET ROCKLIN ROSEVILLE SPORTS COMPLEX SUNRISE WATT

Date 5 You Worked

Date You Worked:

Work Start Time:

Work End Time:

Specific Class Name:

Club Name:--None--ARDEN CARMICHAEL CITRUS HEIGHTS DOWNTOWN ELK GROVE FOLSOM GREENHAVEN LAGUNA MADISON MIDTOWN NATOMAS ORANGEVALE POCKET ROCKLIN ROSEVILLE SPORTS COMPLEX SUNRISE WATT

Date 6 You Worked

Date You Worked:

Work Start Time:

Work End Time:

Specific Class Name:

Club Name 6:--None--ARDEN CARMICHAEL CITRUS HEIGHTS DOWNTOWN ELK GROVE FOLSOM GREENHAVEN LAGUNA MADISON MIDTOWN NATOMAS ORANGEVALE POCKET ROCKLIN ROSEVILLE SPORTS COMPLEX SUNRISE WATT

Date 6 You Worked

Date You Worked:

Work Start Time:

Work End Time:

Specific Class Name:

Club Name:--None--ARDEN CARMICHAEL CITRUS HEIGHTS DOWNTOWN ELK GROVE FOLSOM GREENHAVEN LAGUNA MADISON MIDTOWN NATOMAS ORANGEVALE POCKET ROCKLIN ROSEVILLE SPORTS COMPLEX SUNRISE WATT

Date 8 You Worked

Date You Worked:

Work Start Time:

Work End Time:

Specific Class Name:

Club Name:--None--ARDEN CARMICHAEL CITRUS HEIGHTS DOWNTOWN ELK GROVE FOLSOM GREENHAVEN LAGUNA MADISON MIDTOWN NATOMAS ORANGEVALE POCKET ROCKLIN ROSEVILLE SPORTS COMPLEX SUNRISE WATT

Acknowledgement: I certify that the information on this form lists a- all time worked in the listed months preparing formats, routines, etc. not already recorded in my time clock and b- all expenses not otherwise reimbursed through other forms or process discussed in the GX Department Guideline Document. I did not omit any time or expenses. I understand that providing anything other than truthful and complete data will result in termination from employment.