__ 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 |
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