Biweekly Pay Requirement

		Requested Date*

Company Name

FEIN Number

Address

City

State

Zip

Telephone Number

Method of Pay

Monthly Semimonthly

Total # of Employees

# Non-Exempt Employees

# Exempt Employees

Requestor Address same as Company Address

Additional Details

**If you want a copy of your waiver, print it before submitting the form**

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