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• Pay Increase Request Form

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• Date
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• Employee Last Name, First Name
• Employee ID #
• Department
• Job Title
• Supervisor Name
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• Employee Start Date
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• Current Employee Status Select Full-time Part-time Temporary/Contract
• Current Salary
• New Salary
• Percent (%) Increase
• Effective Date
• Reason for Increase Select Merit Equity Counteroffer Temporary Increase in Duties Permanent Increase in Duties Position Change
• Explain the reason for pay increase.
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• Status of Request
  Approved Denied

  Reason for Denial
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• Supervisor Signature
• Human Resources Signature
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