multiple jobs: yes no personnel authorization … will be performing an instructional assignment yes...

Multiple Jobs: Yes No Position Number: _________________ PERSONNEL AUTHORIZATION REQUEST FORM FISCAL YEAR 2017-2018 (Please remember to always attach a Scope of Work with each PARF)

PART I: COMPLETED BY EMPLOYEE

Legal Name: Last First Middle

DOB: Gender: M F

Banner #: Current employee at Cuesta?

No Yes

Dept. Name:

Current student at Cuesta? Yes No Federal Work Study CalWORKS

Mailing Address: City: State: Zip: Home/Cell Phone:

Email Address: This is the primary method of communication by Human Resources

I have verified my mailing address and understand this is where my paycheck will be sent. Please initial __________

Employee’s Signature: Date:

PART II: COMPLETED BY REQUESTING DEPARTMENT

Earliest Preferred Start Date: End Date:

Division:

Campus: SLO NC SSC

Employee Type: (Ed Code § 88003)

Employee will be performing an instructional assignment Yes No

Employee will need computer access Yes No

(Please submit computer access form to Computer Services)

Position is a categorically funded position. Yes No

Employee will be directly supervised by a member of the Employee’s immediate family Yes No

Employee is: Position Title:

Accounting/Clerical Series:

Range must be from Short-Term/Temporary & Student salary schedule:

Rate of Pay (x) Hrs./Week (x) Weeks Working (=) Estimated Cost

Account String(s): *Acct Code 2320=student, non-instructional 2332= hourly, non-instructional 2421= student, instructional 2431= hourly, instructional2422= student, instructional dept 2432= hourly, instructional dept

FN ORG ACCT* PROG ACT %

PART III: REQUIRED SIGNATURES

Department Contact:

Print Name: Ext:

Web/Dept. Time Entry Information (If Applicable) Approver: (approves the web based timesheet)

Print Name: Ext:

Proxy (approves the web based timesheet when approver is unavailable)

Print Name: Ext:

Supervisor Approval: Print Name:

Signature: __________________________ Date: __________

Director/Coordinator Approval:

Print Name: Date: _________

Signature: ____________________________________

Dean or Vice President Approval:

Print Name: Date: _________

Signature: _____________________________________

Vice President of Human Resources Approval:

Signature: ___________________ Date: _________

Payroll: Human Resources:

W-4 Status: Pay ID: EM MD

TS Org #: Job % BOT Date:

Deductions:

105 OASDI 110 MC 120 SUI 125 WC

Excluded Deductions:

Dues STRS PERS

PERS 6% PERS 7% PERS Retiree PERS Exempt STRS Retiree STRS Exempt None

Entered By: ____ Date: _____

Units ___ EMTC ___ WBTE DTE

Entered By:______ Date: _____ Termed By: ___ Date: ______

Entered By: ____ Date: _______

Support Series: Support Series II:Technical Series:

Special Series: