Employee Action Form — LM Restaurant Group

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Submission Details

Submitting Manager *

Location *

Submission Date *

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Action

Select all that apply.

New Hire Termination Add Location Rate Change Rehire Transfer Leave of Absence Return from Leave

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Employee Information

First Name *

Last Name *

Cell Phone

Email Address

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Termination

Select rehire eligibility and termination reason.

Last Day of Employment *

Eligible for Rehire?

Yes No

Termination Reason

Payout PTO?

Yes No

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Payroll Designations

Primary

Location *

Position *

Pay Rate

$

Default Pay

Additional Position

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Leave

Leave Type

Leave of Absence — From

Leave of Absence — To

Leave With Pay

From

To

Leave Without Pay

From

To

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Return from Leave

Leave Type

Return Date

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Rate Change

Current Rate

$

New Rate *

$

Effective Date

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Additional Notes

Notes / Instructions

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Termination Payout

Accrued Paid Time Off

days

Severance

days

Other

days

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Signature & Approval

Signature *

Sign here

Print Name *

Approval Date *

By submitting this form, the approver confirms all information is accurate and authorized.

Submission Details

Action

Employee Information

Termination

Payroll Designations

Leave

Return from Leave

Rate Change

Additional Notes

Termination Payout

Signature & Approval

Review Submission