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Personnel/Payroll Action Request Form

  1. General

  2. Please Print, Completing Known Information


  3. Present Status:

  4. Action Requested


  5. Provide Applicable Information

  6. New Status:

  7. Separation


  8. __________________________________________________

  9. Employee Signature for Resignation/Retirement


  10. _________________________

  11. Date:


  12. Eligible for Rehire:

  13. Exit Interview:

  14. Approvals:


  15. __________________________________________________

  16. Supervisor Signature and Date



  17. __________________________________________________

  18. Department Director and Date



  19. __________________________________________________

  20. Human Resources Director and Date


  21. __________________________________________________

  22. Controller and Date


  23. __________________________________________________

  24. City Manager and Date



  25. Posted to IMS _____

    Posted to PeopleTrak _____

  26. Leave This Blank:

  27. This field is not part of the form submission.