(For Employee)

Date:

Name of Employee:

Social Security Number:

Position:

Title:

Department:

Date of Most Recent Performance Review:

Results of Most Recent Performance Review:

Previous Raises (if any) and Specify Dates:

Range of Salary Raises within Department
for Similarly Situated Employees:

Justification for Salary Increase:

Specify Type of Increase (i.e. Bonus, Merit, Inflation, etc.):

MANAGEMENT AUTHORIZATION

Request Approved:

Effective Date:

Request Denied: (Specify Reason)

By:

Title:

Department:

Comments:

Date: