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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