Employee Status Change Form
Employee Name
First Name
Last Name
Date
-
Month
-
Day
Year
Date
Job Title
Supervisor
Manager
Manager email
*
example@example.com
Effective Date
-
Month
-
Day
Year
(Preferably the first day of a new pay period)
Current Wage/Salary
New Wage/Salary
Change in Job Title
If yes, new job title
Change in Supervisor
If yes, new Supervisor
Change in Department
Change in PTO
Change in Employment Status
If yes, new status
1. Reason for pay/title adjustment.
2. Are there any expectations moving forward related to this pay adjustment/change in Job title?
3. Does employee need any of the following:
Email address
Please Select
Need to Add
Need to Remove
Laptop
Please Select
Need to Add
Need to Remove
Company truck
Please Select
Need to Add
Need to Remove
D&A pool
Please Select
Need to Add
Need to Remove
Driver
Please Select
Yes
No
Driver Approved
Please Select
Yes
No
Mileage
Please Select
Need to Add
Need to Remove
Other
Please specify any or additional application or folder access the employee will need:
Supervisor Signature
Date
-
Month
-
Day
Year
Date
Approved By:
Date
-
Month
-
Day
Year
Date
Submit
Should be Empty: