Salary Authorization Form
Date
*
 /
Month
 /
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Employee Name:
First Name
Last Name
Employment Status
Please Select
Full-Time
Part-Time
Temporary/Contract
Reason for Increase
*
Temporary Additional Duties
Permanent Additional Duties
Counteroffer
Other
Current Salary ($)
*
Salary Increase/Decrease ($)
*
Salary Increase/Decrease (%)
*
Effective Date
*
 /
Month
 /
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Request Status
*
Reason (if denied)
*
Supervisor Signature
HR Signature
Date Signed
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
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Print Form
Submit
Clear Form
Should be Empty: