Fillable REQUEST FOR EMPLOYMENT / STATUS CHANGE Instructions for (Lurleen B Wallace Community College)

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REQUEST FOR EMPLOYMENT / STATUS CHANGE Instructions for (Lurleen B Wallace Community College)

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File type: PDF

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REQUEST FOR EMPLOYMENT / STATUS CHANGE
Instructions for Employees: Complete Section 1 ONLY.
SECTION 1: EMPLOYEE INFORMATION
Name:
Social Security Number:
Address:
City:
ST:
Zip:
Date of Birth:
Ethnic Origin:
Highest Degree:
E-Mail Address:
Phone Number:
Cell Phone Number:
Emergency Contact:
Relationship:
Emergency Phone:
Employee currently a member of the Teachers Retirement System or Employees Retirement System: Yes No
Employee retired from the Teachers Retirement System or Employees Retirement System: Yes No
Instructions for Supervisors: Complete Section 2, Section 4 (if applicable), sign, date, and return to HR.
SECTION 2: JOB CLASSIFICATION
Check One:
Instructional Staff Professional Staff
Administrative Staff Support Staff
Check One:
Full-Time Temporary
Part-Time Adjunct
Campus Location:
Andalusia Greenville
MacArthur Luverne
Department
Position Title
Date of Employment/Beginning Date:
Ending Date (If Temporary):
Salary
Schedule Rank ________ Step __________
Maximum󠆦
If Hourly; $ Rate Per Hour: Required 󠆦 Hours Per Week ____________
If Adjunct; $______________________ Per CR/HR
Salary in Budget
Yes No
Position Salary Budget Year
Account Number
SECTION 3: EMPLOYEE ELIGIBILITY
Employee eligible to receive leave: Yes No 
If yes, leave class: _______________________
Employee eligible to receive health insurance:
Yes No
Employee eligible for membership in Teachers Retirement System:
Yes No
SECTION 4: IF APPLICABLE
If change of status, specify change and justification:
________________________________________________________________________________________________________
________________________________________________________________________________________________________
Request by: ___________________________________________________________
ImmediateSupervisor’sSignature & Title Date Dean/ V.P. (Initial)
Reviewed by: ___________________________________________________________
Human Resources Coordinator Date CFO (Initial)
Approved by: ___________________________________________________________
President Date
Revised 1-22-2018
Employee #:
OFFICE USE ONLY
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REQUEST FOR EMPLOYMENT STATUS CHANGE Instructions for (Lurleen B Wallace Community College)

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Completed 2 February 2021

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