Report all personnel changes on this form. Send TWO COPIES prior to payroll affected by this change. SUPPLEMENTARY PAYROLL CERTIFICATION AND REPORT OF PERSONNEL CHANGE To: The Glen Cove Civil Service Commission Name of employee: City Hall, 9 Glen Street, Glen Cove, NY 11542 From: Address: Title of Position: Date of Birth: Status: Grade/Step: Social Security Number: Jurisdictional Classification: Salary: Veteran/Exempt Fireman Status: Personnel Change Effective Date: Ending Date: (Only if required below or if seasonal) Nature of Personnel Change (Check only one) Action Necessary by Appointing Officer Permanent - Competitive Return Certification (GCCS-19) APPOINTMENTS Provisional - Competitive Attach Application (GCCS-1) Temporary (Note ending date above) State length of employment under remarks Substitute (Note ending date above) Give facts under remarks For Term of Office (Note ending date above) Give facts under remarks Permanent Promotion Return Certification (GCCS-19) Provisional Promotion Attach Application (GCCS-1 or 1P) Non-Competitive Class Attach Application (GCCS-1) Exempt Class Attach Application (GCCS-1) Labor Class Attach Application (GCCS-1) Resignation Submit signed Resignation TERMINATIONS Retirement Give effective date above Deceased Indicate date above Removal Attach a copy of proceedings Layoff (Lack of Work or Funds) Give facts under remarks Military Leave of Absence Give facts under remarks OTHER CHANGES Other Leave of Absence (Note ending date above) Give facts under remarks Transfer (from one agency to another) Give facts under remarks Reassignment (from one position to another) Give facts under remarks Demotion Give facts under remarks Suspension Give facts under remarks Reinstatement Give facts under remarks Change in Classification Give facts under remarks Change in Salary Indicate new salary above Change in Name Give facts under remarks Other Give facts under remarks Remarks: Appointing officer: Title: Date: CERTIFICATE This certifies that the above employment is By: valid until in accordance with the Law and Rules _________________ made in pursuance to Law. Subject to any Date: (Date) limitation or condition specified above. GCCS-11.1 (Updated 02/07) This form is intended for use when filling out on a computer. An alternate version (GCCS-11.3) of this form is available when filling out by hand.
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