Pinal Gila Community Child Services, Inc

							Pinal Gila Community Child Services, Inc.                                                               HR-1005; Rev. 06/2007; Page 1 of 2

                      EMPLOYEE TRANSFER / PROMOTION / DEMOTION REQUEST
  Employee                                                                              Current
    Name:                                                                              Position:
  Employee                                                                              Current
       ID #                                                                                Site:
Date of Hire:
I am requesting consideration for (check one):                           TRANSFER                    PROMOTION                 DEMOTION

To                                                                                   At
                                       (Position)                                                                   (Site)

How long have you been with PGCCS?                                    How long have you been in your current position?
Please check ALL THAT APPLY:
 Are you currently or have you been related (wife, husband, son,                                              Agency?         Yes    No
     daughter, mother, father, brother, sister, aunt, uncle, niece, nephew, in-law, step,
     foster , grand) to any staff member:
                                                                                               Requested Site/Dept?            Yes    No

 Do you have any disciplinary actions pending at this time?                                                                   Yes    No
     If yes, violation #:                                                   Expected completion date:

EDUCATION / TRAINING HISTORY
         GED / High                   Complete                School:
         School Diploma               In Progress           Location:

         AA / AAS                 Complete
                                  In Progress               Credit Hours Completed:

                                  Major:                                          School:
                                  Minor:                                          Location:

         BA / BS                  Complete
                                  In Progress               Credit Hours Completed:
1                                 Major:                                          School:
0
                                  Minor:                                          Location:
0
5
         MA / MS
                                  Major:                                                    Minor:
                                 School:                                                    Location:

         CDA:                     In Progress       # Modules Completed:                             Anticipated Assessment:
         Infant/Toddler
                                  Current           Initial Date Of Receipt:                               Renewal Due Date:

         CDA:                     In Progress       # Modules Completed:                             Anticipated Assessment:
         Home Base
                                  Current           Initial Date Of Receipt:                               Renewal Due Date:

         CDA:                     In Progress       # Modules Completed:                             Anticipated Assessment:
         Pre-School
                                  Current           Initial Date Of Receipt:                               Renewal Due Date:

         CDA MANAGEMENT                       Where                                                         Date
         CERTIFICATE                        Received:                                                   Received:
Pinal Gila Community Child Services, Inc.                                                        HR-1005; Rev. 06/2007; Page 2 of 2


       ECE CERTIFICATE                     Where                                                      Date
                                         Received:                                                Received:

Please list any additional acquired skills, knowledge or experience you would like considered in assessing your qualifications
for this position.




PGCCS WORK HISTORY                                                         Dates
         Job Title                                             To                         From                              Site




I understand that my most recent Performance Evaluation will be reviewed and my immediate supervisor will be
asked for a supporting reference. I further understand if all minimum qualifications are not met, I will not receive
an interview unless no external candidate is selected. Any false statements during this process will result in
disciplinary action, up to and including discharge.
Employee Signature:                                                                                 Date:
         This request must be received in the Human Resources Department by the posted deadline.
PGCCS will maintain a policy of nondiscrimination with all employees and applicants for employment. No aspect of employment at
PGCCS will be influenced in any manner by race, color, religion, sex, age, national origin, genetic testing results, disability (physical or
mental), veteran or uniformed services status, pregnancy, marital status, medical condition, sexual orientation, membership in a
Uniformed Service or any other classification protected by applicable federal, state or local law.

SUPERVISOR’S SECTION
Evaluate this candidate regarding Current Position and/or Performance (circle only one for each item):
                                    1 = Needs Improvement           2 = Meets PGCCS Job
  Meets Essential Function of Job
  Participated as a Team Player
                   Professionalism
                       Attendance

Capability           In your professional opinion, is this candidate capable of assuming the responsibilities of the
Assessment:          position for which he/she has requested consideration? (Please indicate your assessment and
                     include comments and additional information to support your assessment.)
         Yes        Comments and Additional Information:

         No




Supervisor                                               Supervisor
Print Name:                                              Signature:                                               Date:

Site/Dept                                          Site/Dept                                   Date:
Manger                                             Manger
Print Name:                                          Signature:
Distribution:      Original to Human Resources Manager(attach the most current evaluation, outcome plan and any
                   disciplinary actions within the last 12months for Personnel File).
                   Copy to Supervisory File                                           Date Received: