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Employee Status Change Form
Employee Name
(Required)
Address
(Required)
Current Department
(Required)
Current Position
(Required)
Effective Date
(Required)
Date of Birth
(Required)
Email
(Required)
Pay Change
Type of Change
(Required)
Merit Increase
Promotion
Cost of Living
Other
Other
Current Pay Rate
New Pay Rate
(Required)
Pay Type
(Required)
Per Hour (Non-Exempt)
Bi-Weekly Annual Salary (Exempt)
Annual Salary
$ (If Exempt)
Status Change
Type of Change
Location Change (Transfer)
Position Change
Leave of Absence
Team Change
Other
Select all that apply
From (Market/Address)
To (Market/Address)
Previous position title
New position title
From
To
Previous Team
New Team
Other
Remarks
Form Filled Out By:
(Required)