City of Martinsville Employee Action Form

Current Time:

Employee Name:Department:Employee #:
Instructions: Complete the informationbeing changed/requested and submit to Human Resources. Actions affecting the pay and/orstatus of an employee
should be submitted no later than the 15th of each month, in order for the action to become effective within the month requested. Personal data change
requires the employee's signature.
Action to be Taken(Check all that apply)Personal Data or Change
New Hire/Rehire

Reinstatement

Suspension

Termination*

Effective:


*Complete Exit
Evaluation for employees
under the City Manager		Pay Change:
Promotion
Transfer
Demotion
Reclassification
Temporary or
Acting Status
Effective:		Leave:
With pay
Without pay
Reason for Leave:
Worker's Comp
FMLA
Military
Temp Disability

Leave Duration:
From:
To:
Has all Leave been Exhausted:
Yes
No
Name:
Social Security #:
Sex:Race:Marital:
Date of Birth:
Address:
City:
State:Zip Code:
Home Phone:
Personal Email:
Emergency Contact Information:
Proposed Change In Classification/Salary
Current Status
Classification:
Location Code:
Position Number:
Budget/Org Code:
Grade:Salary:AnnualHourly

Full-timePart-time
Temporary Duration:

FLSA Status:ExemptNon-Exempt


Supervisor:		Proposed Status
Classification:
Location Code:
Position Number:
Budget/Org Code:
Grade:Salary:AnnualHourly

Full-timePart-time
Temporary Duration:

FLSA Status:ExemptNon-Exempt


Supervisor:
Replacing:
Effective: