FOR HUMAN RESOURCES DIVISION ONLY



|FOR HUMAN RESOURCES DIVISION ONLY | | |

| | |LOS ANGELES COUNTY PUBLIC WORKS |

| | |HUMAN RESOURCES DIVISION |

| | |REPORTS OF CHANGES IN PAYROLL/PERSONNEL INFORMATION |

| FAS | | |

|CWTAPPS | | |

|PSR | | |

|INITIAL |     |DATE |  /  /   | | |

| | | | | | |

| |Effective Date: |      |

|Changes made in: Name Address Div/Section Post. No. | | |

|(Please check as | | |

|applicable) Phone No. Pay Location Org I.D. No. | | |

|Employee Name: |               |Employee Number: |      |

| |Last First M.I. | | |

|Current Classification: |      |New Div/Sect: |      |

|Please complete information below as checked above (Please print): |New TKU Location: |      |

|Former Name (if changed): |               |Old TKU |      |

| | |Location: | |

| |Last First M.I. | | |

|New Phone |Home |(   )   -     |New |      |

| | | |Classification: | |

|Number: | | | | |

| |Work |(   )   -     |New Pos. No: |      |

|New Address: |                 | | |

| | |New OCA No: |      |

| |Number Street Apt. No. | | |

| |               | | |

| |City State Zip Code | | |

|If personal information changes, employee must sign. |Submitted by: |      |Date: |  /  /   |

| | | |

60-0004 PW Rev. 05/19

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