__ Employment  __ Terminate  __ Change

Explanation________________________________

Employee	Employee #			S. S. #			Grade Level
Address		City			State	Phone
Job Title	Department		Location			Phone

Employment

__New Hire    __Rehired    __Temporary  __Part Time    __Replacement For:
Hire Date	Start Date	Age	Sex	Marital Status	Education	Shift

Termination 

__Voluntary __Involuntary		Last Day Worked	Pay Through Date		Rehire? __Y__N
Hire Date	Start Date	Paid Days Accrued		Severance Pay Approved?  __Y__N

Change 

__ Rate/Salary  __ Job __ Location			Leave of Absence: From ___________   To __________
Location Change	To:			From:
Job and Salary Change		Old Title/Salary			New Title/Salary

Comments 

 Approval Signatures

Prepared By:	Date	Supervisor:	Date
Audited By:	Date	Personnel:	Date
Employee:	Date	Personnel:	Date