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Payroll Change Template

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Payroll Change Template
Payroll Change Template
EMPLOYEE: _______________________________ POSITION: ____________________________________
EFFECTIVE DATE: ____________________________________
REQUEST FOR: (check applicable box(es) and indicate appropriate information)
Employment Hourly Rate*: __________________ Average Daily Hours: ________________
Beginning Time: __________________ Ending Time: ____________________
Length of lunch period if not paid: ____________________________________
Salary Amount: $ __________________ Years Experience: _______________
Contract Period From: __________________ To: ___________________
Change of Position From: ______________________ To: ______________________
Change of Rate From: ______________________ To: ______________________
Leave of Absence From: ______________________ To: ______________________
Termination Resignation Other, explain on reverse side
Please complete the following section for terminations/resignations:
Attendance ____________________________________________________________________
Punctuality ____________________________________________________________________
Job Performance _______________________________________________________________
Evaluation Comments ___________________________________________________________
Areas of Concern ______________________________________________________________
Would you re-employ ___ yes ___ no Why ____________________________________
State reason for recommendation:
_________________________________________ ________________________________________
Recommending Supervisor Date
_____________________________________________ _____________________________________________
Finance Manager Date
____________________________________________ _____________________________________________
Executive Director Date
*This section MUST be completed to comply with record keeping requirements of Wage and Hour Law.
J:\SSURECS\Sct\My Forms\payroll change auth1-jcb.doc
Payroll Change Template