EMPLOYEE STATUS CHANGE
EMPLOYEE PROFILE
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Employee Name: |
Social Security #: |
Date: |
Date Effective: |
CLASSIFICATION CHANGES
Change |
Old Information |
New Information |
Transfer |
Title/Dept: |
Title/Dept: |
Promotion |
Title/Dept: |
Title/Dept: |
Demotion |
Title/Dept: |
Title/Dept: |
Title |
Title/Dept: |
Title/Dept: |
Shift |
Shift: |
Shift: |
Location |
Location: |
Location: |
Salary |
Salary: |
Salary: |
Status |
Status: |
Status: |
Merit Bonus |
Reason: |
Amount: |
Other change:
Notice of COBRA rights? |
Date Provided: |
Election of COBRA? |
Start Date: |
ADDITIONAL COMPENSATION/BENEFITS INFORMATION |
Please list any changes in compensation and benefits:
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
Please list any other changes, not listed above:
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
VERIFICATION OF CHANGES |
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Manager Signature
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Date
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Approved By
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Executive Signature
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Date