LAUX MSD 426-A (7/1/72)
Report all personnel changes on this form.
Send TWO COPIES prior to payroll affected by this change.
SUPPLEMENTAL PAYROLL CERTIFICATION AND
REPORT OF PERSONNEL CHANGE
DATE
___________________________________
TO: Orleans County Civil Service Commission
14016 Route 31 W Albion NY 14411
FROM:
_______________________________________________________________________________
Department
_______________________________________________________________________________
Name & Title of Last Employee in Position
________________________________________________________________________________
Name of Employee
________________________________________________________________________________
Address
________________________________________________________________________________
Title of Position
_______________________________________________________________________________
Salary
Veteran Non-Veteran
Disabled Veteran
Exempt Volunteer Fireman
_______________________________________________________________________________
Date of Birth Social Security Number
A
P
P
O
I
N
T
M
E
N
T
S
Check nature of Personnel Change Date Effective Action necessary by Appointing Officer
Permanent Return report of certification
Provisional Attach application (MSD 330)
Temporary From to State length of employment
Substitute From to Give facts under Remarks
For Term of Office From to Give facts under Remarks
Permanent Promotion Return report of certification
Provisional Promotion Attach nomination
Non-Competitive Class Attach application (MSD 330)
Exempt Class Submit this form only
Labor Class Attach application (MSD 330)
T N
E A
R T
M I
I O
- N
S
Resignation Submit Signed Resignation
Retirement Give Effective Date
Deceased Indicate Date
Removal Attach copy of proceedings
Lay-Off (Lack of Work or Funds) Give facts under Remarks
O
T
H
E
R
C
H
A
N
G
E
S
Military leave of absence Give facts under Remarks
Other leave of absence From to Give facts under Remarks
Transfer Give facts under Remarks
Demotion Give facts under Remarks
Suspension Give facts under Remarks
Reinstatement Give facts under Remarks
Change in Classification Give facts under Remarks
New Position Submit Form MSD 222
Change in Salary Indicate New Salary
Change in Name and/or Address Give facts under Remarks
Other Give facts under Remarks
REMARKS: (Continue on back if necessary)
Appointing Officer:
Title:
Address:
CERTIFICATE
valid until
______________________
(Date)
This certifies that the above
employment in accordance with Law
and Rules made in pursuance to Law.
Subject to any limitation or condition
specified above.
By: _________________________________
Date: _______________________________
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