Free 45123.xls - Indiana

PERSONNEL / PAYROLL ACTION
State Form 45123 (R2 / 3-07)

INDIANA STATE PERSONNEL DEPARTMENT

Reset Form

Requisition Number

Personal Data
Employee ID: Address Line 1: Employee Name: (Last, First, Middle Initial) Address Line 2: Effective Date of Action:

Address Line 3:

City:

County:

State:

ZIP Code:

Education Level:

Gender: Male Female Telephone:

Marital Status:

Marital Status Date:

Date of Birth:

Date of Death:

Ethnic Group:

Social Security Number:

Job Data
Effective Date: Position Number: Location: Effective Date Seq No: Department: Regular Intermittent Business Unit: Job Code: Temporary Position Title: Working Leader: Yes Company: SOI BMVC Paygroup: Employee Type: Exception Hourly Salary Hourly No Full Time Part Time Tax Location: 999 Holiday Sched: SO1 Salary Plan: Action Code: Employee Class: Appointed Elected Intermittent Judicial Legislative Non-Merit Sum Intern Temporary Reason Code:

Standard Hours: Merit OriginalWT Perm Stat PromoWT XOrig WT XPromoWT Compensation Frequency: Bi-Weekly Hourly Compensation Rate:

37.5 Other

Change Amount: $ per

Grade: Step:

or Change Percent:

Benefit Program Participation Data
BAS Group ID: Benefit Program: Elig Config 1: Effective Date of Benefit Program:

Job Labor
Union Code: Union Seniority Date:

Employment Data
Company Seniority Date: Service Date: Date Last Worked: LOA Expected Return Date: Permanent Status Due Date: (Probation Date)

Emergency Contact Data
Primary Emergency Contact: (Last, First, Middle Initial) Relationship: Contact Telephone: Address Line 1: City: Address Line 2: County: Home: Business: Address Line 3: State: ZIP Code:

Secondary Emergency Contact: (Last, First, Middle Initial)

Relationship:

Contact Telephone:

Home: Business: Address Line 3: State: ZIP Code:

Address Line 1: City:

Address Line 2: County:

Employee's Signature:

Date:

Signature of Appointing Authority:

Date:

Signature of SPD Director: Comments:

Date: