Personnel Change Notice
__ Employment __ Terminate __ Change Explanation________________________________ Employee Address Job Title Employee # City Department S. S. # State Location Phone Phone Grade Level
Employment __New Hire __Rehired __Temporary __Part Time __Replacement For: Hire Date Start Date Age Sex Marital Status Education Shift
Termination __Voluntary __Involuntary Hire Date Start Date
Last Day Worked Paid Days Accrued
Pay Through Date
Rehire? __Y__N
Severance Pay Approved? __Y__N
Change __ Rate/Salary __ Job __ Location Location Change Job and Salary Change To:
Leave of Absence: From ___________ To __________ From:
Old Title/Salary
New Title/Salary
Comments
Approval Signatures Prepared By: Audited By: Employee:
Date Date Date
Supervisor: Personnel: Personnel:
Date Date Date
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