Request For Personal Action - Department Of Administration

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DEPARTMENT OF ADMINISTRATION
REQUEST FOR PERSONNEL ACTION
See the Department of Administration Supervisor’s Manual for list of attachments to be included with this Request for Personnel Action.
EMPLOYEE’S FULL NAME
SOCIAL SECURITY NUMBER
EFFECTIVE DATE
CONTACT CODE
DIVISION
SUPERVISOR’S NAME
EMPLOYEE‘S NAME FOR EMAIL PURPOSES
EMPLOYEE’S PHONE NUMBER
EMPLOYEE’S FAX NUMBER
FROM:
TO/OR NEW
:
POSITION TITLE
POSITION CONTROL NUMBER
RANGE/STEP
LOCATION/DUTY STATION
ACCOUNTS(S) CHARGED
CC
LC (if used)
CC
LC (if used)
TYPE OF ACTION
Probationary Full-time Appointment
Separation/Resignation
Probationary Part-time Appointment
Dismissal
Partially Exempt/Exempt Appointment
Transfer to _
__________________________
Nonpermanent Appointment
Retirement
Separation/Appointment (Part-time to Full-time or
To Leave Without Pay
Nonpermanent to Permanent or vice versa)
Return from Leave Without Pay
Promotion
Layoff
Demotion
Return from Layoff
Salary Increase
Change in Accounts Charged
Employee Contact Information Change
Other____________________________________
COMPLETE THIS SECTION UPON SEPARATION, LAYOFF or LEAVE WITHOUT PAY
REASON FOR RESIGNATION:
TO BE COMPLETED BY ALL EMPLOYEES: (please initial each statement as applicable)
______ I will, OR______ have surrender(ed) all Equipment ______ Keys ______Key cards ______ Corporate Cards______
Phone Cards ______ ID Cards ______ Purchase Cards ______ Notary Commission ______ Parking Tags ______
______ I will, OR ______ have clear(ed) all matters pertaining to petty cash funds _______ training reimbursement ______
travel expenditures (TR books, travel advances, field warrants, relocation expenses) ______
______ I have received the SBS annuity refund and tax forms
______ My mailing address has changed and is noted below in the Remarks Section. (*final paycheck, W2, PERS)
______ I have been informed of health and/or life insurance continuation rights and options
______ I have received the Retirement and Benefits PERS Refund Election form
______ I have contacted the Deferred Compensation office (if applicable)
DATE:
EMPLOYEE’S SIGNATURE:
SUPERVISOR’S SIGNATURE:
DATE:
REMARKS: *Note: There is no Direct Deposit for Final Pay
Revised 10/17/2000

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