GCCS 11 1 Report of Personnel Change by 2xuH469


									                                                              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)

                       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

                       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 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

 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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