Last Name:	First Name:	Week Ending (Sunday):
Email Address:
Hourly Information:
Mon (Date): Time In: Time Out for Break: Time in from Break: Time Out: Hours:
Tue (Date): Time In: Time Out for Break: Time in from Break: Time Out: Hours:
Wed (Date): Time In: Time Out for Break: Time in from Break: Time Out: Hours:
Thu (Date): Time In: Time Out for Break: Time in from Break: Time Out: Hours:
Fri (Date): Time In: Time Out for Break: Time in from Break: Time Out: Hours:
Sat (Date): Time In: Time Out for Break: Time in from Break: Time Out: Hours:
Sun (Date): Time In: Time Out for Break: Time in from Break: Time Out: Hours:
Total Hours:
Reimbursement $ (if applicable): [please forward receipt to office]	Mileage (if applicable): Please explain reason for requesting mileage:	.
Facility Name/Location for this pay period:
Certify:
I certify that all information provided herein is accurate and true and that I have worked the hours listed above.
Please check this box if you agree to the certifying statement. By checking this box you are providing an electronic signature.
Date:

Please note: Your attendance sheet is still required to be submitted each week. If you are unable to scan and email your attendance sheet, please email Martha (MarthaB@LNAHealthCareers.com) and Rebecca (Rebecca@LNAHealthCareers.com) any information on students who missed time (be sure to include the date they missed, how much time and their reason) and all test grades if applicable for the week.