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Personnel Action Form

2. Effective Date
   Effective Date

4. Employee Information

6. Name

8. Employee Number

10. Employment Status

    1. Appointed
    2. Elected
    3. Full-Time

    1. Part-Time
    2. Seasonal
    3. Temporary

12. Current Department

14. Current Job Title

16. Personnel Action Details
    Please Complete All Applicable Fields

    Please Complete All Applicable Fields

18. Adjust Hours Worked (Per Pay Period)

    1. Yes

19. Proposed Employment Status

20. Proposed Hours Worked (Per Pay Period)

22. Adjust Annual Salary or Hourly Wage

    1. Yes

23. Current Annual Salary or Hourly Wage

24. Proposed Annual Salary or Hourly Wage

26. Transfer (Change Job Title and/or Department)

    1. Yes

27. Proposed Department (If Applicable)

28. Proposed Job Title (If Applicable)

30. Approval Signatures

32. City Manager

33. Date
    Date

35. Department Head

36. Date
    Date

38. Human Resources

39. Date
    Date

Leave This Blank:


41. 1. Receive an email copy of this form.
42. Email address

    This field is not part of the form submission.

43. Submit

* indicates a required field