EMAIL OF PERSON SUBMITTING REQUEST:

TELEPHONE NUMBER OF PERSON SUBMITTING REQUEST:

ACTION:
Add:    Update:    Correct:    Delete:

Please include any information below that will help process this request.

EFFECTIVE DATE:    EMPL.ID:     DEPT.ID: 

DEPARTMENT NAME:    EMPL.RCD.NBR.:         

POSITION NBR.:   

NAME: (Last, First, MI)  

SOCIAL SECURITY NUMBER:

ORIGINAL HIRE DATE 

HOME ADDRESS    MAILING ADDRESS  

ADDRESS 1

ADDRESS 2

CITY         STATE   COUNTY     

COUNTRY 

HOME PHONE            ZIP

OTHER PHONE NUMBERS:

TYPE                 NUMBER 

GENDER:
Female Male    Unknown      

MARITAL STATUS

HIGHEST EDUCATION LEVEL

MARITAL STATUS DATE

BIRTHDATE    DATE OF DEATH

REFERRAL SOURCE  

CITIZENSHIP STATUS   ETHNIC GROUP

EMPLOYMENT ELIGIBILITY PROOF 1:

EMPLOYMENT ELIGIBILITY PROOF 2:

DATE ENTITLED TO MEDICARE  MEDICARE NUMBER 

MED A EFFECTIVE DATE  MED B EFFECTIVE DATE

MILITARY STATUS 

Go To SUBMIT

EFFECTIVE DATE        EFFECTIVE DATE SEQUENCE

ACTION CODE            REASON CODE  

POSITION NUMBER    TAX LOC.

JOB CODE (Defaults from Position Data)

FICA STATUS

GRADE/STEP  RATING SCALE

COMPENSATION RATE

(unclassified positions only when entering Comp Rate)

Probation   Permanent Trainee   Not Applicable

Go To SUBMIT     

PROGRAM EFFECTIVE DATE         ELIGIBILITY CONFIG FIELD 2

BENEFIT PROGRAM             

DATE LAST LONGEVITY BONUS   DATE LAST WORKED

DATE NEXT INCREASE   EXPECTED RETURN DATE

BENEFIT RECORD NUMBER   BUSINESS TITLE

Add Years Subtract Years  

Add Days   Subtract Days 

PERB:                                                                  PHONE NUMBERS:

EFFECTIVE DATE                             PHONE TYPE

PERB UNIT                                                NUMBER