PERSONNEL ACTION FORM
Employee Name: ___________________________________________________________ Last First Middle Initial Address: ________________________________________________________________________________________ Phone number: ___________________________________________________ Last 4 of SS#: ___________________ Type of Action: Incentive Pay Promotion/Transfer Leave of Absence Appointment Salary Change Separation
Effective Date:
Title: Salary: Step:
Appointment Type: Permanent Probationary Full Time Part Time Temporary Remarks:
Date: Department Head: Date: City Manager:
Date: HR/Finance: Date: Council (If Applicable):
Title Title
From Department To Department
Salary: Step: Salary: Step:
Title: Salary: Step:
Reason: Resignation Dismissal Lay Off Retirement Deceased End Temporary Work Duration of City Employment: From: To:
APPOINTMENT
SEPARATION
SALARY CHANGE OR PROMOTION/TRANSFER
Street Address City State Zip Code