Employee Replacement Request

EMPLOYEE REPLACEMENT REQUEST

Request Summary

Requestor Name:   Department:

Request Date:   Contact Phone:   Email:

Position to be Replaced

Reason for replacement:

Last Day Worked (incumbent):   Desired Start Date (replacement):   Status:

Exempt/Non-Exempt:   FTE:   Current Salary / Budgeted Range:

Business Justification

Describe the business impact if this role is not filled and provide justification for replacement (include critical duties and deadlines):

Recruitment Plan & Options

Hiring Manager:   Reports to:

Recruitment Type: Backfill New Headcount Internal Only External / Open

Proposed Candidate (if known)

Candidate Employment History (Provide at least two entries)

Title:   Dates:   Reason for leaving:

Title:   Dates:   Reason for leaving:

Education & References

Institution:   Graduation:

Compliance & Certifications

At-Will Employment:

I acknowledge that this request pertains to employment terms that may be subject to at-will employment doctrine where applicable. Nothing in this request creates a contract of employment for a definite term.

Equal Employment Opportunity:

The organization is an equal opportunity employer. Recruitment and selection must comply with applicable nondiscrimination laws and internal policies.

Authorization to Contact and Background Check:

By submitting this request I authorize HR to initiate reference checks, verify employment history, and conduct background screening as required by policy for the proposed candidate. Select to confirm: I authorize contact and background checks

Applicant Certification (if a candidate is supplied): I certify that the information provided regarding the proposed candidate and related supporting information is true and complete to the best of my knowledge. Falsification or omission may be grounds to terminate recruitment or employment.

I certify the above statement

Budget & Approval Information

Cost Center / Account Code:   Position Budgeted: Yes No

Finance Approval: Approved Not Approved   Date:

HR Approval: Approved Not Approved   Date:

Additional Notes / Attachments

Note any job description updates, required equipment, relocation requirements, or attach supporting documentation to this request (attachment via HR system recommended).

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