Champaign County Personnel Information Form
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1CHAMPAIGN COUNTY PERSONNEL INFORMATION FORM
Lateral Transfer____
Promotion ____
Transfer to Lower Salary ____
Other ____
Employee Information
Employee Name: ____________________________________________
SSN: _____/ _____/ _____
Address: __________________________________________________
DOB: _____/ _____/ _____
Phone: __________________
Gender: _________
Marital Status: ___________
Race: _______________
Position Information
Position Title: ______________________________________________
Effective Date: _____/ _____/ _____
Office/Dept: ____________________________
Annual Hours: ______________
Status: ___________________
Bargaining Unit (if any): ____________________________
Pay Grade: ____________
Salary: ______________
Reason for Starting Salary Recommendation: ____________________________________________________________
Former Employee in Position: _________________________
Date Former EE Termed: _____/ _____/ _____
ADA Training Req’d (Check all that apply):
IL Relay
Counter Staff
None
Already Complete
Computer Access Request
Add program: _____________________________________________________________________________________
Delete program: ___________________________________________________________________________________
OR use same profile as: ___________________________________________________
Parking Permit Request (Courthouse Employees Only)
Vehicle #1 Make/Model: _________________________________
License Plate: _________________________
Vehicle #2 Make/Model: _________________________________
License Plate: _________________________
Date Submitted: _____/ _____/ _____
By: ___________________________________________
Elected Official/Department Head/Designee
EMAIL COMPLETED FORM TO:
eboatz@co.champaign.il.us
Payroll Authorization
Approval Authority: ________________________________
Start Date: _____/ _____/ _____
Hourly Rate: _____________________
Bi-Weekly Rate: ___________________
Annual Rate: ______________
Notes: ___________________________________________________________________________________________
Approved: ____________________________________
Date Approved: _____/ _____/ _____
Evelyn Boatz
Salary Administration Authorization
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Parent category: Business