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Simple Personnel Action Form

Name *

First

Last

Date of Birth *

Email *

Department *

Supervisor *

First

Last

Action:

If other, please explain

Reason for Action: *

Type of Employment *

Please Describe Part-time Position

Total Part-time Hours

Is There a Position Change? *

Describe the position change

Please include all details including position titles, wage differences, date of move, etc.

Department Manager *

Human Resources Representative *

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