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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
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
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35. 1. Receive an email copy of this form.
36. Email address

    This field is not part of the form submission.

37. Submit

* indicates a required field