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: