Status Change Form

Status Change Process Form

Effective Date of Change:(Required)

If resignation, please list last day of working (please also attach resignation letter below):

Future position title:(Required)

Future Status (Full-Time, Part-Time, PRN, etc):(Required)

Total hours to be worked each pay period:(Required)

Weekend rotation:(Required)

Yes

Holiday rotation:(Required)

Yes

Hours of shifts:(Required)

New wage? If so, please list:(Required)