EMPLOYEE REQUISITION
No.
COMPANY NAME
DEPARTMENT/ORGANIZATION NAME
SHIFT
PAY GRADE
PERSON HIRED
STARTING DATE
STARTING RATE OF PAY
RACE
MARITAL STATUS
Human Resources Representative Signature Date
SOCIAL SECURITY NUMBER
SEX DISABILITIES VETERAN BIRTH DATE
Z NUMBER
BENEFIT DATE SIGN IN
Date Time
FM065 Rev: 12012014
REMARKS:
SIGNATURES/APPROVALS:
TO BE COMPLETED BY HUMAN RESOURCES
PAY RANGE:
(Call Human
Resources for
pay range.)
MINIMUM MIDPOINT
MAXIMUM
SHIFT DIFFERENTIAL RATE OF PAY
LUNCH PERIOD
PAYROLL CODE
ORGANIZATION NO. NO. OF
EMPLOYEES
o REPLACEMENT FOR:
o SALARY OF EXITING EMPLOYEE:
o ADDITIONAL POSITION:
o FULL TIME/REGULAR
o
o
1 HOUR
ON-CALL PAY
o YES o NO
o NEW HIRE
o Hour
o PPP
o Yes o No
o M o S
o Yes o No
o REHIRE o TRANSFER
o HOURLY o NON-EXEMPT
o SALARIED o EXEMPT
o NO LUNCHo
1
/
2
HOUR
o 2nd o 3rd o ROTATING o ECB
o FULL TIME/SEASONAL/TASK
o PART TIME/REGULAR
o PART TIME/SEASONAL/TASK
IF PART TIME, NO. OF FTE’s:
IF SEASONAL, LENGTH OF EMPLOYMENT:
JOB TITLE
Supervisor Date
(1)
Department Manager/Chair Date
(2)
Dean/Director Date
(3)
Vice Pres./Provost Date
(4)
Human Resources Date
(5)
Budget Date
(6)
Chief Financial Officer Date
(7)
1st
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