Notice of Hire - Employment Status and Acknowledgement of Wage Rate(s)

Sep 16, 2026

Notice of Hire form for recording an employee’s hiring status, employment type selection, and acknowledgement of wage rate(s). Captures employer and employee identification details, pay frequency and designated payday, and any allowances claimed as part of wages such as tips, meals, or lodging. Includes sections for tipped employees, minimum/living wage basis, pay and overtime rate information, prevailing rate job classifications, agency enforcement contact, and employee/employer signatures. Also contains instructions for completing each section.

LanguageEnglish

CategoryLetters

FormatPDF

Pages4

Reading Time2 min

AccessFree to download

Notice of Hire

Employer and Employee Information

Pay Frequency and Pay Day

Allowances Claimed As Part of Wages

Tipped Employees

Basis of Wage Payment

Prevailing Rate (if applicable)

Department of Employment Services Contact

Employee Acknowledgement

Instructional Guide

NOTICE OF HIRE – EMPLOYMENT STATUS AND ACKNOWLEDGEMENT OF WAGE RATE(S) | Notice of Hire (Check only one) | | | --- | --- | | □ At Hire □ Current Employee □ Annual–Current Date □ Change in pay rate(s) or payday Effective Date: / / | | | Section 1 | | | Employer | Employee | | 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: ( ) - | | Section 2 | | | Pay Frequency and Payday | | | Pay Frequency: Designated Pay Day: (Weekly, bi-weekly, semi-monthly, monthly, etc. ) (Day of week when wages are payable/available) | | | Section 3 | | | Allowances Claimed As Part of Wages: □ None, or: | | | □ Tips $ per hour
□ Meals $ per meal
□ Lodging $ per
□ Other $ per | | | Section 4 | | | Tipped Employees | | | 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) | | | Section 5 | | | --- | --- | | Basis of Wage Payment | | | □ Minimum Wage □ Living Wage □ Living Wage Exempt □ Employer Determined Wage Rate | | | Pay Basis: (hourly, shift, day, week, salary, piece, commission) | | | □ Hourly | □ Multiple Rates or Basis (for each type of basis) | | Rate of Pay: per hour
Overtime Rate of Pay* per hour
□ Overtime Pay Exemption for bona fide
□ Administrative
□ Executive
□ Professional | 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. | | Section 6 | | | □ Prevailing Rate (if Applicable) | | | 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: | | | Section 7 | | | 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](at owh.ask@dc.gov . The office)[ ](at owh.ask@dc.gov . The office)[owh.ask@dc.gov](at owh.ask@dc.gov . The office)[ . The office](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 . | | | Section 8 | | | 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

FAQs

What information must be completed in Section 1 for Employer and Employee?

Section 1 requires completing all employer and employee fields, including company/employer details and the employee’s name and addresses (physical and mailing) plus phone contact.

How should the pay frequency and payday be specified?

Section 2 requires indicating the frequency for regularly scheduled wage payments (e.g., weekly, bi-weekly) and the specific payday day of the week when wages are payable/available.

What must be included under “Basis of Wage Payment” in Section 5?

Section 5 requires selecting the wage basis (minimum wage, living wage, living wage exempt, or employer-determined wage rate), specifying the pay basis type(s) (hourly, shift, salary, piece, commission, etc.), and providing the actual rate(s). It also requires overtime rate information or a stated exemption with the reason.

Sep 16, 2026

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