personnel action Request Form Re-Hire "*" indicates required fields Requestor Email* Select your Region VP* Carlos Rivera Eric Wheeler Jaime Restrepo Edita Gargovic Elgar Quijandria Effective Date* MM slash DD slash YYYY Section 1: Employee Information Employee Name* First Middle Last Last 4 SSN*Home Address* Street Address City StateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Date of Birth* MM slash DD slash YYYY Telephone* Section 2: Assignment Information Home Department*Job Number*Job Title*Pay Rate*Scheduled Days To Work* Mon Tue Wed Thu Fri Sat Sun Scheduled Work Hours*Select* Union Non-Union Select* Added Position Employee Replacement Replaced Employee*ReasonSignature* Δ
