POIETO INC · HR Forms

Notice to Employee

Labor Code §2810.5 · California Wage Theft Prevention Act · Complete at hire and on any change

CA Labor Code §2810.5
DLSE NTE — Revised 2024
Retain in personnel file 3 years

This notice must be provided to non-exempt employees at time of hire and within 7 days of any change to the information below (unless the change is reflected on a timely wage statement). Exempt employees are not covered. For each new hire, fill in the blank fields, print two copies, sign both, give one to the employee, and file one in their personnel file.

Section 1 Employer Information Pre-filled · verify before printing

Legal name of employer

POIETO INC

Doing business as (if different)

—

Physical address of main office or principal place of business

267 S Spring St 3L, Los Angeles, CA 90012

Mailing address (if different)

1206 Maple Ave Suite 1032, Los Angeles, CA 90015

Employer telephone number

contact@poieto.com

POIETO INC is the direct employer. No staffing agency or labor contractor is involved in this placement.

Section 2 Employee Information Fill in per hire

Employee full name *

Date of hire *

Job title / role

Work location(s)

Section 3 Rate(s) of Pay and Basis Fill in per hire

Pay basis	Regular rate	Overtime rate (1.5Ã)	Double time rate (2Ã)
Hourly Salary	â	â	â

Employee is paid at two or more rates. (Attach schedule of rates and the work to which each applies.)

Employee is exempt from overtime. Basis of exemption:

Section 4 Allowances Claimed as Part of Minimum Wage (if any)

Meal allowance

Lodging allowance

Other (describe)

Section 5 Regular Payday and Pay Schedule Pre-filled · verify with Bernie before printing

Pay period frequency

Every two weeks (bi-weekly)

Regular payday (day of week or date)

Section 6 Basis of Employment Agreement

The terms of employment are set out in a written offer letter dated . A copy has been provided to the employee.

Section 7 Workers' Compensation Insurance Pre-filled · confirm policy number with Bernie

Insurance carrier

The Hartford

Carrier phone

800-327-3636

Policy number *

76 WEG AU1HD6

Section 8 Signatures Sign in person · both parties retain a copy

I hereby acknowledge receipt of this Notice. I understand the above terms of my employment and that this Notice does not alter the at-will nature of my employment.

Employee signature

Date

Employee printed name

Christine Meinders · Founder & CEO · POIETO INC

Employer representative (pre-filled)

Employer signature

Date