LOUISIANA DEPARTMENT OF STATE CIVIL SERVICE



Employee Change Form for Paper AgenciesRevised: 07/2021Effective Date: FORMTEXT ?????LaGov HCM Personnel Number: FORMTEXT ?????Nature of Action: FORMTEXT ?????SCS Rule Number for Action: FORMTEXT ?????Agency Name: FORMTEXT ?????Agency Personnel Area: FORMTEXT ?????Employee’s Name: (Last name, First name, MI)Permanent Status: ? Yes ? No ? N/A FLSA Status: ? Exempt ? Non-ExemptEffective Date of Permanent Status:Job Posted by SCS: Yes FORMCHECKBOX No FORMCHECKBOX Minimum Qualifications Met: Yes FORMCHECKBOX No FORMCHECKBOX LA Careers Requisition Number: CURRENTPROPOSEDJOB TITLE FORMTEXT ????? FORMTEXT ?????JOB CODE FORMTEXT ????? FORMTEXT ?????POSITION NUMBER FORMTEXT ????? FORMTEXT ?????PAY SCHEDULE/GRADE FORMTEXT ????? FORMTEXT ?????RATE OF PAYHourly:Bi-Weekly:Hourly:Bi-Weekly:OTHER/SPECIAL PAY FORMTEXT ?????WORK HOURS (FT or PT) FORMTEXT ????? FORMTEXT ?????CONTRACT TYPEAPPOINTMENT END DATECOMMENTS/JUSTIFICATION FOR TEMPORARY APPOINTMENTS & PAY CHANGESThe next section is to be completed if the employee’s address is changing, ONLY:Employee’s Address: FORMTEXT ?????City: FORMTEXT ?????State: FORMTEXT ?????Zip: FORMTEXT ?????Check here if this a new address FORMCHECKBOX Check here if you are reporting a change of address only on this form FORMCHECKBOX Check here if you are reporting a name change only on this form FORMCHECKBOX Agency Contact InformationContact Name: FORMTEXT ?????Email Address: FORMTEXT ?????Phone: FORMTEXT ?????I hereby certify that all information on this document is true and correct to the best of my knowledge.Appointing Authority Signature: FORMTEXT ?????Title: FORMTEXT ????? Date: FORMTEXT ?????Electronic Submission:Scan form as PDF & upload via Paper Agency Portal in the HR Info Portal. ................
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