Ppersonnel Action Form//change Of Address Form

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PERSONNEL ACTION/CHANGE OF ADDRESS FORM
I.
Effective Date of Action Recorded Below: ______________________________________________________
Employee Name: _____________________________________
PLU ID ______________________________
Title: _______________________________________________
Department: _________________________
II.
Change(s)
From
To
 Dept Account Number
 Position Title
 Position Number
 Salary Grade
 Salary/Pay Rate
 FTE
 Benefits Status/Ecls
 Supervisor
 Campus Address/Phone
 Home Address/ Phone*
(*No approval required
except employee’s
signature)
Signature
Phone ______________________
Phone ____________________
_______________________
III.
Reason for Change(s)
 Hired/Replacement for: ___________________
 Salary Grade Change/Adjustment: ________________
 Re-Hired: ______________________________
 Title Change
 Promotion: _____________________________
 Leave of Absence (Call HR for details)
 Lateral Transfer: ________________________
 Reclassification of Existing Job (Call HR for details)
 Beginning Phased Retirement: _____________
 Other Reason (Please Specify) __________________
 FTE Change: ___________________________
_____________________________________________
IV.
Authorization
Vice President approval required for all changes affecting the budget.
Request: ________________________________
Recommend: ___________________________________
Budget Head
Date
Vice President
Date
Approve: ________________________________
Process: _______________________________________
Human Resources Associate VP
Date
Payroll Department
Date
FOR HUMAN RESOURCES USE ONLY
 Employee File
 Payroll
Copies Distribution:
Entered in Banner:
Date:
Revised March 2015

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