Rate Change Form

Submitter Name *

Store # *

Employee Name *

ID#

Reason for Rate Change: *

Please elaborate if necessary for supporting reason for rate change:

Current Position *

Future Position *

Current Rate *

Future Rate *

Employee E-mail 🛈

Employee Email

Effective date of rate change(Must be the begining of the next pay period) * +

Your rate of pay is confidential. You are not to share your rate of pay with any other employee or person: this will result loss of any raise given and possible termination. Do not show this form to anyone. It is for your records only.

Date of rate change should be at the beginning of the Next pay cycle. Pay rates cannot be changed in the middle of a pay cycle or in the past.

This form should be turned into the Director of Operations for submissions to the payroll department. Rate changes will not be honored unless they have been inputted into the ISP on the effective date and this form has been signed by all parties. All rate changes will be communicated via General Manager and/or Area Supervisor only with this form present and given to the employee at the time of discussion after AS and DO have signed off. Print this form for signature.

ISP *

Changed in the ISP (incl Date changed) Changed in the ISP (incl Date changed)

By inserting your initials below you are agreeing that the above has been executed properly

General Manager Name

Area Supervisor Signature *

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Employee Signature *

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