Distribution: Original - HR COPY - Payroll COPY - Department COPY - Employee Rev. 8/17
BONNEVILLE COUNTY
REQUEST FOR PERSONNEL ACTION
EMPLO
YEE NAME: Employee No.:
PERSONAL INFORMATION: (For current employees complete only items which have changed)
A DDRESS: Date of Bi rth:
PHONE:
WO
RK/EXT:
EMERGENCY CONTACT INFORMATION
NAME AND RELATIONSHIP:
ADDRESS:
PHONE:
WO
RK/EXT:
PAY & STATUS INFORMATION:
CURRENT
PROPOSED
DEPT./DIV. - FUND/DEPT. CODE
POSITION TITLE AND CODE
STATUS: PT, FT, OR TEMP.
HOURS PER WEEK
PAY GRADE AND STEP
PAY RATE
REASON FOR CHANGE
NEW HIRE
REHIRE
T RA N SFER
MERIT STEP INCREASE
REALLOCATION
RECLASSIFICATION
PROMOTION
DEMOTION
PROBATION
LEAVE WITHOUT PAY
SUSPENSION WITHOUT PAY
SUSPENSION WITH PAY
RETIREMENT
RESIGNATION
LAYOFF
TERMINATION
DEATH
OTHER (EXPLAIN)
EXPLANATION OF ACTION:
EFFECTIVE DATE: NEXT SALARY DATE: LAST EVALUATION DATE:
APPOINTING
OFFICIAL:____________________________________________
REVIEWED
BY:____________________________________________________
(Human Resource Department)
DATE ___________________________
DATE ___________________________
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