Personnel Change Notice                         

  Date:                                   

  Employee Name:                                SSN:                                    

  
                       Employment or Change Information

      þ Employment                        þ Change

        þ Full Time                         þ Rate/Salary:                                   
        þ Part Time:                        þ Employee Data:                             
        þ Temporary:                        þ Other (specify):                              
        Start Date:                         þ Effective Date:                                
   
           Catagory             Previous                   New/Starting
  
                            Termination Information

      þ Voluntary                    Final Day of Work:                                      
      þ Involuntary                  Accured Paid Time Off:                                
                                     Severence Pay Approved:                               
  Reason for Termination (Attach any supporting documentation):                                                  
                                                                                                                              
                                                                                                                              
   
                                   Approvals

  Department Manager:                           Date:                              
 
  Executive Director:                           Date: