New Hire Rehire

Phone: 1-800-621-1308 Data Change Position Change

Fax: 1-888-621-1309 Status Change Salary Change
Leave of Absence Termination
PERSONNEL ACTION NOTICE Other ________________________
• Supervisor MUST complete appropriate
(PAN)
Section thoroughly
Company Name: ______________________________________

Personal Information (use this section for Data Changes)

Name: ______________________________________________________ Social Security Number: __________________________

Last First MI

Address: _____________________________________________________________________________________________________
Mailing Address City State Zip County

Phone Number: ( )________-_____________ Date of Birth: ______/_______/_______

New Hire or Rehire Effective Date: ____/____/____ Original Worksite Date of Hire: ____/____/____

Job Title: ____________________________________ Pay Frequency: Weekly Bi-Weekly

Semi-Monthly Monthly

Pay Status: Hourly Salary (Is this employee Exempt or Non-Exempt ?) Commission

Work Status: Full Time Part Time Temporary Other: _____________________

Rate of Pay: $ ____________ Division: __________________ Department: _____________________________

WC Code: _________ Job Code: _________

City, County & State Worked: ____________________________________________________________________________

Salary Change Effective Date: ____/____/____

Old Rate: $ _____________ Reason for Change: _______________________________

New Rate: $ _____________ Pay Frequency: Weekly Bi-Weekly
Semi-Monthly Monthly

Transfer Effective Date: ____/____/____

Location Department Division Transfer To _______________________ From ________________________

(Check One)

Status or Position Change Effective Date: ____/____/____

Status Change: (check one) Position Change

Full Time to Part Time To: ___________________________
Part Time to Full Time From: _________________________

Leave of Absence Effective Date: ____/____/____

Medical Personal Workers Comp Other: ____________________________________

Does Employee Have Benefits: Yes No

Termination Effective Date: ____/____/____

Voluntary Resignation
Attendance (Attach Documentation)
Performance (Attach Documentation)
Insubordination
Does Employee Have Benefits: Yes
No Call/ No Show 2+ days (list last day worked: _____________)
Lack of work/ Lay off
Other: _______________________________________
No

Remarks:
__________________________________ Supervisor’s Signature
__________________________________
__________________________________ ___________________
__________________________________ Date