Retiree Rehire Request Form
Submit a request to rehire a retired employee. Please complete all relevant details for review and approval.
Retiree Full Name
*
First Name
Last Name
Retiree Email Address
*
example@example.com
Retiree Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Previous Job Title
*
Previous Department
*
Date of Retirement
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Reason for Rehire Request
*
Proposed Rehire Position
*
Proposed Department
*
Proposed Rehire Start Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Immediate Supervisor Name
*
First Name
Last Name
Immediate Supervisor Email
*
example@example.com
HR Representative Name
*
First Name
Last Name
HR Representative Email
*
example@example.com
Additional Comments or Notes (optional)
Please sign below to confirm the accuracy of the information provided and submit your request for approval.
*
Submit Request
Submit Request
Should be Empty: