Personnel Action Form

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Personnel Action Form
__ Employment __ Terminate __ Change
Explanation________________________________
Employee
Employee #
S. S. #
Grade Level
Address
City
State
Phone
Job Title
Department
Location
Phone
Employment
__New Hire __Rehired __Temporary __Part Time __Replacement For:
Hire Date
Start Date
Age
Sex
Marital Status
Education
Shift
Termination
__Voluntary __Involuntary
Last Day Worked
Pay Through Date
Rehire? __Y__N
Hire Date
Start Date
Paid Days Accrued
Severance Pay Approved? __Y__N
Change
__ Rate/Salary __ Job __ Location
Leave of Absence: From ___________ To __________
Location Change
To:
From:
Effective Date
Old Title/Salary
New Title/Salary
Comments
Approval Signatures
Prepared By:
Date
Supervisor:
Date
Audited By:
Date
Personnel:
Date
Employee:
Date
Personnel:
Date

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