Employee Status Change Form

Employee Name:  ____________________________________________________

Effective Date: _____/_____/_____ Change: (check appropriate reasons)

Job Information:     Title       Supervisor     Work Schedule

         Wages*:        Merit      Promotion      Adjustment

* Please attach appropriate paperwork form for wage increase.

Description of change:

________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

Separation of Employment:   Resignation     Involuntary Termination

Reason:___________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

Eligible for rehire?      Yes       No

Employee Signature ___________________________________ Date: _____/_____/_____

Manager Signature: ___________________________________ Date: _____/_____/_____