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Personnel Action Form

Employee:
firstlast name
Instructions
Check the appropriate box and fill in the information in the blanks below. Employee signs only if he/she initiates action or payroll deduction is required. Supervisor signs in all cases.
___ Payroll ___ Promotion ___ Change of address
___ Payroll Decrease ___ Leave of Absence ___ Change in dependents
___ Transfer ___ Separation ___ Classification change
___ Payroll Deduction  
Change in Pay or Classification
FromTo
Pay ________per________ ________per________
Classification
TO BE EFFECTIVE
Separation
___ Laid off for lack of work ___ Discharged for felonious conduct
___ Left work voluntarily ___ Other reason
___ Discharged for repeated willful misconduct
Remarks (Final pay check, date, amount, etc.):
Eligible for rehire? ___ Yes ___ No
Other (changes, deductions, etc.)
Employee Signature / Date
Supervisor Signature / Date
Copyright 1998 Steven M. Sack

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