WORK SCHEDULE CHANGE REQUEST

WORK SCHEDULE CHANGE REQUEST
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Current Employment Status*

Full TimePart TimePer DiemLeave of Absence
Employment Status Requested*

Full TimePart TimePer DiemLeave of Absence
Effective Date*

MonthDayYear
Date
Please provide reason for change of status:*
I understand changes could require altering hourly rate, benefits, job status, work days, etc. Any alterations would be discussed with supervisor prior to them being in effect.
Signature*
Today's Date*

MonthDayYear
Date
To be completed by owner or supervisor
Supervisor or Owner

First NameLast Name
Approval Status

ApprovedNot approved
Effective Date of Change

MonthDayYear
Date
Comments:
Supervisor/Owner Signature
Date

MonthDayYear
Date
Should be Empty:

To be completed by owner or supervisor