DIY Legal Forms

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Employee Status Change

Name

Employer Tax. I.D. Number:

Department

Effective Date

Wage/Salary/Title Change:

Title:

Grade Pay Rate

Increase [--%]

Present:

Proposed

Type of Change: (Check Appropriate One)

[ ] 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:

Signature

Department Manager

Date:

Signature

Personnel Manager

Date:

IMPORTANT: Original to be sent to the Department Manager, and a copy to Personnel File.