Employee name: ______________________________________________
Effective date: ____________________ Today's date: ________________
Instructions: Check the appropriate box and fill in the information below.
[] Initial hire | [] Transfer | [] Promotion | [] Termination |
[] Benefit change | [] Wage change | [] Payroll deduction | [] Classification/status |
[] Address change | [] Phone change | [] Leave of absence | [] Other: |
| EMPLOYMENT CHANGES |
|---|
New job title: ______________________________________ |
New classification: [] Full-time [] Part-time |
New wage rate: __________ Percentage change: _____ |
New status: [] Exempt [] Nonexempt |
New manager/department: ________________________ |
Instructions: _________________________ |
| BENEFIT CHANGES |
| Benefits Affected: [] Medical [] Dental [] LTD [] Life [] 401(k) Instructions: ________________________________________________________ |
Signatures: (Employee signature is necessary only if a payroll deduction is required. Supervisor and director sign in all cases.)
Supervisor: ____________________________ Date: ___________________
Director: ______________________________ Date: ___________________
Employee (if applicable): __________________ Date: ___________________
To be completed by human resources:
Changes completed by: _________________ Date: ____________________
Payroll updated by: _____________________ Date: ____________________
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