EMPLOYEE NAME	DATE of FORM
EMPLOYEE ID	DATE EFFECTIVE
POSITION TITLE	DEPARTMENT

PAYROLL CHANGE FORM TEMPLATE

TYPE OF REQUEST

NEW EMPLOYMENT	BEGIN DATE	END DATE	OPEN
AVG DAILY HRS	START TIME	END TIME
LENGTH OF UNPAID BREAKS	LENGTH OF PAID BREAKS
HOURLY RATE	SALARY AMT
CONTRACT POSITION	INITIAL RATE	REVISED RATE
CHANGE OF POSITION	INITIAL RATE	REVISED RATE
CHANGE OF RATE	INITIAL RATE	REVISED RATE
LEAVE OF ABSENCE	INITIAL RATE	REVISED RATE
TERMINATION (COMPLETE SECTION BELOW)	RESIGNATION (COMPLETE SECTION BELOW)	OTHER
IF “OTHER,” EXPLAIN
ATTENDANCE
PUNCTUALITY
JOB PERFORMANCE
EVALUATION COMMENTS
AREAS OF CONCERN
IS RE-EMPLOYMENT AN OPTION?	YES	NO	WHY?

REASON FOR RECOMMENDATION

STATEMENT OF NEED
SPECIAL NOTES

AUTHORIZATION

DIRECT SUPERVISOR	DATE
FINANCE DEPARTMENT	DATE
EXECUTIVE DIRECTOR	DATE