Employee Change Form

Employee Name:	Client Company:
Last 4 of Social Security Number:	Employee Number:
Effective Date:

PERSONNEL / PAYROLL CHANGE

Action Taken:	FROM	TO
Position / Title Change
Leave of Absence
Address/Phone Change – Complete Below
Pay Change
Separation – Complete Below
Workers’ Compensation Code
Employee Status (Full-time, Part-time)
Department Change
Other Action
Additional Comments:
Address/Phone Change:

TERMINATION OF EMPLOYMENT

Last Day Worked:	Employee Was: Full-time Part-time Temporary Other
Check One: Voluntary Involuntary
Was termination conducted in cooperation with your (or another) Xenium Business Partner? Yes No If yes, with whom did you collaborate?
Termination Reason	Termination Reason	Termination Reason	Termination Reason
Resignation – Other Position	Violation of Company Policy-See File	Staff Reduction	Terminated-Continue Commission Pay
Resignation	Unsatisfactory Performance	Employee not worked in 60 days	Mutual Agreement to Separate
Returned to School	Attendance	Leave of Absence	Retired
Elimination of Position	Reduction In Force	Temporary Assignment	Death
Job Abandonment	Lay-Off	Transfer	Other
Misconduct
Additional Comments:

SIGNATURES

Employee Signature	Client Representative Signature	Xenium Representative Signature
Date:	Date:	Date: