Employment Status

FOR ALL PERSONNEL ACTIONThis box must be completed entirely for ALL actions.
Effective Date of Action(Date action needs to take place): Employee No.:
Name (First, Middle, Last):
Mission Unit No.:

EMPLOYMENT STATUS

Please check one:
SalariedFull Time Hourly/FTHourly/PT
Salaried PartTime (average monthly hours): / Check if applicable:
Overseas Multicultural
Seasonal Temporary Non-Paid

NEW EMPLOYEE INFORMATION

Preferred Name: Maiden Name:
Date of Birth: Sex:
Address:
City: State: Zip:
Phone:() - Cell Phone:() -
E-mail:
Attachments:
YL ApplicationIRD FormDirect Deposit
I-9 FormCopy of Social Security CardFederal W-4 FormState W-4 Form
Country of Birth:
Ethnic: American Native Asian or Pacific Islander Black Hispanic White Native Hawaiian
More Than Two Races
Worked as paid Young Life staff before? Yes No
Spouse’s name, if married: Spouse’s Date of birth:
SALARY INFORMATION/CHANGEIf this is a salary increase, please provide explanation in “OTHER” section.
JobTitle / Salary Range No.
:Choose an item.
Total stated salary $per monthOR hour
(Do not include COLA)
From Mission Unit No.:
If reducing/reinstating current salary, check appropriate box:
Voluntary reduction BEGIN Regional deficit BEGIN
Voluntary reduction END Regional deficit END / COLA% (if applicable)%
If salary is split, fill out the following:
$ fromMission Unit No.
$ fromMission Unit No.
$fromMission Unit No.
Supervisor:
(Regional Dir., Fie1d Dir., CampMgr. orService Center. Dept. Dir. only)

MANSE ALLOWANCE

/

LODGING DEDUCTION(for campStaff)

$ per monthWorksheet attached
If newly declared manse:
Ordination certificate attached / $per month
Please check one:
Required Convenience
LEAVE OF ABSENCE (LOA) All paid staff.*Note: Prepare a separate PAR to end LOA.
Check one: Personal Financial (3 months benefits) Worker’s Comp Maternity
Beginning Ending(If returning as paid staff, complete Salary Information section.)
Reason for leave:
During periods of nonpaid leave, the staff personmay not perform the duties prescribed by their Young Life job description.

TERMINATION

Reason for termination: Choose a reason.
E-mail (required for exit survey):
Last day worked: Unused vacation days:
TRANSFER To be completed by area RECEIVING the staff person.
Transferring FROMMission Unit No.:
Transferring TOMission Unit No.:
Please include state W-4 for staff transfer if applicable.

NONMEDICAL BENEFITS

/ SPECIAL INSTRUCTIONS/ COMMENTS
Health Club (attach receipt)

Exercise Equipment (attach receipt)

SERVICE CENTER USE ONLY

Personnel / Compensation / Payroll

AUTHORIZED BY:(Regional Dir., Fie1d Dir., Camp Mgr. or Service Center. Dept. Dir. only)

Name:Date:
Title: