Free Statement - District Court of Arizona - Arizona

. Personnel Change of Statue Notice _
To Be Completed By Supervlaor page; -6, 1179)
Starting Date Effective Date ot Change
’ { -· I1/1 /9 '&"°(D;
P esent Salary Laat Day worked Replacement for Whom
EMPLOYMENT _ _ Z ·__._
.. — . / " `C9 h ‘—\
N¤¤¤-lll! of l¤¢f•¤8•" Amount New Salary• Date Last Increase & Amount :
rz
` New Supervisor New Department New Job Title Salary Paid
RESIGNATION (Check One) DISMISSAL (Check One) _
_ DISSATISFIED WITH: UNSATISFACTORY PERFORMANCE DUE TO: ‘
D PAY (Explaln why below) (Show date ol Corrective Interview)
_ El JOB (Explaln why below) lj Aeszurezlsu
El WORKING CONDITIONS (Explain why below) EI TARDINESS .
Cl ANOTHER POSITION (Explain below) KINABILITY TO PERFORM JOB .i....;
. Cl HEALTH REASONS (Explain below) - CI ATTITUDE
. E1 MATERNITY (Explain below) EI REDUCTION OF FORCE
Cl MILITARY SERVICE (Explaln below) El HEALTH REASONS (Explain below)
EI DECEASED V U MISCONDUCT (Explaln below)
Cl ANY OTHER REASON (Explaln beIow)_ El ANY OTHER REASON (Explain below) _
_ Explanatlon and Comments (Be Speclllc)
in ·" ' - 11,/ g, .-
ll . = T e ‘?9 . -,
I _•• ~ O X ¤~ 5 · 5O ma': "IZ>—»<€"> *C=9(
‘ Check Ott: Key Turned In Unltorme Tumed In El SOP BookD Interview- Vlce Pres. U Final lntervievog
. Sales Developer D Remelnlnq Eamlnqe Pold — Amount S
._ ‘ Vqoatlon to be Peld - Amount S ___;_____ P4 Reason for Termlnatlon Explalned to Termlnated Employed
N Addre New Phone Other Data l
PERSONAL °"' °°
CHANGES e
LEAVES °°‘°°
CI Leave of Absence From _ To
· El Slck Leave Explanation - .
El Vacatlon
C1 Special Request
Supervisor Requee · ha Date
APPROVALS I _
A - ` A .. . r’/ . 2/ O Z!
- l {Ill
I ' I
l EXHIBIT
_` § J DE FS 000 1 59
Case 2:03-cv-01913—IVIHIVI Document 66-12 ?iIed 1/2006 Page 1 of 1 _

Case 2:03-cv-01913-MHM

Document 66-12

Filed 03/31/2006

Page 1 of 1