Weekly Salary Employee Payment Claim Form

Route #:*

Name:*

Week #:*

Email:*

SERVICES PERFORMED

DAY OF
WEEK

CUSTOMER

NUMBER

NAME

NUMBER OF SERVICES PERFORMED

A/W

O/S

OTHER

DAILY
HOURS

BILLING $

DAY OF WEEK

CUSTOMER

NUMBER

NAME

NUMBER OF SERVICES PERFORMED

A/W

O/S

OTHER

DAILY HOURS

BILLING $

DAY OF
WEEK

PROSPECT NAME

NUMBER OF TRIALS INSTALLED

A/W

O/S

OTHER

DAILY
HOURS

BILLING $

DAY OF WEEK

PROSPECT NAME

NUMBER OF TRIALS INSTALLED

A/W

O/S

OTHER

DAILY HOURS

BILLING $

Day

Mileage

Mon

Tue

Wed

Thu

Fri

Sat

Sun

TOTAL

@ COST PER MILE

$0.50

SUB TOTAL

Sub Total:

Base Salary/Commission Percent:

Total:

TOTAL WEEKLY CLAIM:

(Miles, Hours, Commission)

I Confirm that this is an accurate statement of my activities.

DATE:

Alternative: