Personnel Change Notification Form (Pcn)
ADVERTISEMENT
1Last Updated 3/6/2015
PERSONNEL CHANGE NOTIFICATION FORM (PCN)
To Be Completed By Supervisor
EMPLOYEE PERSONAL INFORMATION
Name: _________________________________
SSN: ____________________________________ Home Phone: (_____)______________________
Yes, Provide copy of S.S. card with new last name to Human Resources with PCN
-- Name Change: ____
.
-- Address changes updated by employee in ADP Portal. -- HR uses Form W4 for new employee address.
Please Circle: New Hire
□ Replacement -Provide Name of previous employee ___________________________
□
Re- Hire
Headcount Increase (REQUIRES EXECUTIVE AUTHORIZATION)
NEW HIRE INFORMATION
Working Interview
Effective
Date: __________Job Title: ________________ Manager: _______________ Location Name: _________________
Starting salary or Hourly
Rate: ___________________
□ Per Hour □ Per Bi-weekly
□ Per Semi-Monthly
Status:
Type of Status:
□ Full
□ Hourly
-time
□
□ Salaried
Part-time
□ Working Interview
JOB INFORMATION (CHANGE/TRANSFER)
Current Position:
Change to:
Effective Date: ____________________
□ Merit □ Promo □Transfer Adjustment_____ □ Other___
Current Location: __________ Current Job Title: ___________
New Location: ______________ New Job Title: _______________
Provide Name of employee replacing:
__________________________________
Current Status: __F/T ___P/T Current Supervisor _________________
New Status: ___ F/T ____P/T New Supervisor::______________________
Current Salary $ _________ (Hourly Rate, Biweekly Salary, Semimonthly Salary)
New Salary $___________ (Hourly Rate, Biweekly Salary, Semimonthly Salary)
LEAVE OF ABSENCE (LOA)
Type of Leave:
Reason for Leave: _______________________________________________________________
□
Last Day Worked
FMLA
: _________________________
Duration of Leave from:
□
Military
_______________________ to _______________________________
□
Estimated Return Date
Actual Return Date
Funeral Leave
: ___________
: _________________
□
Other___________________
TERMINATION
Type of Termination:
Eligible for Re-Hire:
Resignation Letter:
□ Voluntary
□ Yes
□ Yes--Attached
□ In-Voluntary (Write-up Attached)
□ No
□ No
□ Laid-Off
□ Unable to Return from LOA
Actual Last day Worked: ____________________ Termination Date: ________________
EMPLOYEE SIGNATURE AND AUTHORIZATIONS
Comments: ______________________________________________________________________________________________________
_________________________________________________________________________________________________________________
I hereby certify that all information on this form is accurate. I also authorize the changes required by the proposed change of status:
Manager (Print Name) ________ _______________________________ Signature ___________________________________
Date ______________
Regional Manager (Print Name):_________________________________Signature____________________________________
Date: ______________
Executive Mgmt. _____________________________________________Signature____________________________________
Date ______________
Employee (Print Name): _______________________________________Signature____________________________________
Date: ______________
FOR OFFICE USE: ADP:____ Medical:_____Vol. Benefits:____ STD:_____ LIFE:______ LTD _____401K: _______Flex: ______ Vision: _____
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business