Employer Tax. I.D. No:

Department

Effective Date

Wage/Salary/Title Change:

Title:

Grade Pay Rate

Increase %

Present:

Proposed

Type of Change: (check appropriate type)

[ ] Voluntary Resignation

[ ] New Hire

[ ] Promotion

[ ] Other

[ ] Leave of Absence

[ ] Sick Leave

[ ] Transfer

[ ] Layoff

[ ] Termination

[ ] Return from Absence

[ ] Disability - Non-Work

[ ] Disability - Work

If leave of absence, state duration - From

To

Comments and reasons for change:

Submitted by:

Supervisor Title

Date

Approvals:

Department Manager ____________________ Date:

Personnel Manager _____________________ Date:

Note: Original to Department Manager, copy to Personnel File.