I worked on Sunday ____________________
(date) without a technician present at store number __________.
I agreed
to take an on call lunch and during my on call lunch period it was necessary
that I fill a prescription. Please provide me with my extra one half (1/2) hour
pay.
Pharmacist's Name:
_______________________________________
Pharmacist's
Signature: __________________________________
Date
Submitted: ___________________________________________
Name
of Person Form Submitted to: ___________________________
Pharmacists - please retain a copy for your
records.