__ 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