< C o mp a n y s na me h e r e >

PAY RATE CHANGE FORM

EMPLOYEE:
HIRE DATE: ___________________
CURRENT PAY RATE: $ ________________ HOURLY / SALARY (CIRCLE ONE)
PAY RATE TO: $_________________ HOURLY / SALARY (CIRCLE ONE)
EFFECTIVE DATE OF CHANGE: ________________
REASON FOR CHANGE: _______________________________________________________________________
________________________________________________________________________________________________
AUTHORIZED BY: DATE:
DATE EMPLOYEE WAS NOTIFIED OF CHANGE: __________________
EMPLOYEES SIGNATURE: _________________________________________
CHANGE MADE IN COMPUTER: (INITIALS & DATE): _______________________

PAY RATE CHANGE NOT VALID UNTIL SIGN BY <insert person(s) here.