Employee Status Change Form
DATE
/
Month
/
Day
Year
Date
LOCATION/STATION
*
Please Select
KBSI/WDKA
KLKN-TV
SMG - CORP
WLNE
REQUEST STATUS
*
Please Select
New Hire
Rehire
Termination
Information Change
Additional Information
EFFECTIVE DATE
/
Month
/
Day
Year
Date
EMPLOYEE INFORMATION
Name
*
First Name
Middle Name
Last Name
Social Security No.
DOB
*
/
Month
/
Day
Year
Date
Phone No.
Work Email
*
example@example.com
Personal Email
example@example.com
Address
Unit Number
City
State
Zip Code
Marital Status
Single
Married
Gender
Please Select
MALE
FEMALE
OTHER
WAGE INFORMATION
Job Class
Please Select
PT Weekly Hourly
FT Weekly Hourly
FT Weekly Salary
Weekly Draw
PT Semi-Monthly Hourly
FT Semi-Monthly Hourly
FT Semi-Monthly Salary
Semi-Monthly Draw
Rate
Commission
Job Title
Department
Supervisor
Termination Reason
Severance Information
Eligible for Rehire?
Please Select
Yes
No
Voluntary/Involuntary?
Please Select
Voluntary
Involuntary
Additional Notes
Requester Name
*
Requester Email Address
*
example@example.com
Approver Signature
Clear
Submit
Should be Empty: