Payroll Authorization
Academic Affairs One Course Per Form
The payroll authorization must be completed and approved before an individual begins work. Responsibility
for obtaining approval rests with the area in which the employee is to work. Payroll Authorizations are marked
received by Human Resources when signatures 1-3 are complete.
FName______________________ LName__________________________ A # ____________________
Department_____________________________ Job Title___________________________________
All fields must be completed Fund_________ Org ________ Acct________ Prog______ %__________
Ex. 1000 10650 6010 60 25%
Fund_________ Org ________ Acct________ Prog______ %__________
Ex. 3200 32410 6010 80 75%
Check One Regular 12 month Regular 10 month Regular 9 month Temporary Pool
Supplemental/Overload Adjunct Summer First Time Online Other
Faculty/Adjunct pays one course per form
Give number currently enrolled in course As of Date:
Projected Enrollment If less than 10 students, provide rationale for offering the
course in Explanation/Special Conditions.
Check One New position Replacement for Other
Average Hours per Week__________________ No. of Weeks (or Reg or Pool)___________
Hourly Rate or Salary Total Authorized
Date on Payroll__________________________ Date off Payroll______________________
Explanation/Special Conditions_____________________________________________________________
1) Supervisor/Dean Approval____________________________________ Date ______________________
2) VP Approval_______________________________________________ Date ______________________
3) Budget Approval ___________________________________________ Date ______________________
For HR Office Use
Employee Class:____________________________ TIAA Enrollment Date:____________________
FTE:______________________________________ BCBS Enrollment Date:___________________
No. of Pays: 20 26 Other Date to Payroll:__________________________
MPSERS Member: Yes No Position Number:________________________
If Yes, Retiree: Yes No Date of Retirement: _______________
Completed by____________