WORK SCHEDULE CHANGE REQUEST

WORK SCHEDULE CHANGE REQUEST
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Current Employment Status

Full TimePart TimePer DiemLeave of Absence
Employment Status Requested

Full TimePart TimePer DiemLeave of Absence
Effective Date

MonthDayYear
Date
Please provide reason for change of status:
I understand changes could require altering hourly rate, benefits, job status, work days, etc. Any alterations would be discussed with supervisor prior to them being in effect.
Signature

Clear
Today's Date

MonthDayYear
Date
To be completed by owner or supervisor
Supervisor or Owner

First NameLast Name
Approval Status

ApprovedNot approved
Effective Date of Change

MonthDayYear
Date
Comments:
Supervisor/Owner Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

To be completed by owner or supervisor