1305 Del Norte Rd.

Camarillo, CA 93010
(805) 654-9814
Service to Achieve Growth and Empower (SAGE)
Personnel Action Notice (PAN)
Employee Name:
Employee Hire Date:
Employee Pay Schedule (Weekly/Semimonthly):

Employee Status Change(s): Defined as any changes to the employee’s status for job title, employment status
(part/full time), and/or changes to compensation/benefits. Check the applicable box(es) below.
Title/Employee Status Change (Exempt, Non-Exempt, Temporary, Full-Time, Part-Time)
✓ Compensation Change
Benefit Change
Information
Prior Employment Title & Employee Status
Prior Rate 1 Wage (Daytime 8:00am-10:00pm)
Prior Rate 2 Wage (Overnight 10:00pm-8:00am)
Prior Rate 3 Wage (Other), if Applicable
Prior Travel Time Wage
Prior Mileage Reimbursement
Prior Phone Stipend
Prior Department
Effective Date Information
New Employment Title & Employee Status
New Rate 1 Wage (Daytime 10:00pm-8:00am)
New Rate 2 Wage (Overnight 10:00pm-8:00am)
New Rate 3 Wage (Other), if Applicable
New Travel Time Wage
New Mileage Reimbursement
New Phone Stipend
New Department
Reason for Change: (Merit, Equity Adjustment, Promotion, Other)
Effective Date
Introductory Period Ending Date
Health Benefits Eligibility Effective Date
Vacation/Holiday/Bereavement Eligibility Effective Date
Sick Pay Eligibility Effective Day
T
e
SAGE adheres to the policy of employment at-will, which permits SAGE or the employee to terminate the employment relationship at
any time, for any reason, with or without cause or notice. My signature acknowledges I have read, understand, and agree to the status
and wages regarding my employment with Service to Achieve Growth and Empower.

Employee Signature: _________________________________ 11/14/2022

x Date: _____________

Management Signature: _______________________________ Date: _____________

t Page 1 of 1