Document zQrM3ge3EJ1bz9ry1E62yY4ma
1 ' CY-RI 006826
Chicago
6507 - B. T e rzic
nr
Election on Termination of Employment
_ American Cyanamid Company
Read the Prospectus related to the Plan beftJ>IRng dtitthisJonn*Terms.used are defined iii^/Appendix to the Prospectus.
This form should be forwarded by the Personnel or EmpioyelPSMtefKs Representative; to the Employees Savings Plan Supervisor, Clifton,
New Jersey 0701Si
PLEASE PRINT. FILL IN ALL APEUCAMM UNSHADED AREAS.
CLOCK CARO NO. SOCML SECURITY NO.
WORK LOCATION
So 7
CJ-UCAQa
EMPLOYEE NAME (Last Naina (comma,
lama (space) Initial)
OATE OP BIRTH
OATS Of
T i 5 ^ 11C
l' 1 I I I I
II I
EMPLOYMENT
SaUEtL3r ii frd
CURRENT EMPLOYEE ADDRESS
'NUMBER AND STREET
\sux
iB R
Sh Vi 1 (i W i i i i i i i i i i i
CITY l, Q\ h ft Qi ft St i i i i i i i i i i i i i i , i , i
APT. NO.
i III! STATE ZIP COOE Aik <J Q| ' 1 l g
AUTHORIZATION FOR DISTR IHUT ION OF FUNDS
I am terminating my employment with the Company on (data) i/Ct/fto
and authorize a distribution of the full value of my Individual Accounts and my Company Account in which t am vested in the form indicated below.
TYPE OF DISTRIBUTION
I hereby elect to have the full value of my Individual Accounts and the vestedportion of my Company Account paid as follows: (Check and complete only one option It -
. Option 1
When e member ceasesto be an employee, if the member then has a spouse, thevalue of the accounts to which
the member has righfewill be appiisd to the purchase of a noiHransferabla annuity providing monthly pay* ments to the member forjife and, thereafter, monthly-payments of 50% of the monthly payment made to . the member to such^pESe, .if sunrivingj-forthe lifeasHpeh spouse. The annuity shall be determined by the in> . ; surance compen*uauingdfee annuitycertificete, anddtafWjein accordance with itsthen applicable policies
(including poiiciesaetamihiihtifn'Tiientthi'ip.annuttiesiiY
50%.joint;ant^c.^iiC survivorannutys-v>
. . :. ,U
r;
j \
\
A.
r
CY-RI 006827
Emi Contribution Changa Application
' ' '1
iiwmi,'
American Cyanamid Company
Read the Prospectus related to the Plan before filling out thiTjgfgx-'^Wrm used are defined in the Appendix to the Prospectus.
This form must be forwarded by the Personnel or Employee Benefitsoepartment Representative to ensure receipt by the Employees Savings
Plan Supervisor, Clifton, New Jersey 07015, at least 10 days before the enrollment data on which you want the change(s) implemented. PLEASEPRINTOR TYPE.
CLOCK CAPO NO.
WORK LOCATION
PAYROLL LOCATION
PAYROLL CODE
fewiPLOYEE NAME (Lest N ime i comma, ipac^TTim Name (ipaca) Initial)
-
T6
JiOi-AfM iy i i i i i i i i i i i i i i i
CURRENT EMPLOYEE ADDRESS
NUMBER AND STREET t i(>i iAl i Bi ft Oirti-& Vi \ i S\ U4 i i i i i i i
CITY it OiiNl ftRt .ft i i i i i i ( ..................................... .......
i i
iii ii i iii
-1 r-r --
7 7/ ,,
,i
1111
APT, NO.
i flit
STATE ZIP CODE 11 4 3 A
^
In accordance with the Plan provisions, I authorize the Company and/or the Plan Trustee to:
t r
*v r.
\
Matched Contribution: I my Matched Emj
CHANGE7 IN PERCENTAGE OF7 CONTRIBUTIONS
Contribution to:
O 1% 0 2%
3%
r
i
Unmatched Contributions.
^Change my Unmatched Employee Contribution tos
1%- 0 2% 3% 0 4* 0 5% CTflfc. ai% n8% 9%
i . .. I understand that a change in the percentage of the matched and/or unmatched payroll deduction rnay-be made-aa of any enrollment date,
but not nwre than twieeeach inany12-month-periocL 1furdm umierstai0ddtthefim:3% ofcmy contribution is matched by the Companyat 5Q%iandno:unmatched is permitted uplessmynoitched.contributiq|^te^^^~^; ~
laev-yv- i f-- -oawcutfWStaiU is rodutimnsc .-'t bn* t>*Tsiaf'tj *i-mto^
.'v'-
m 221984
CY-RI 006829
20 ..
PART NO. 3
WML-1.463
cHecic r b s u is it io m
TO CASHIER'S DEPARTMENT
V/.
AMERICAN CYANAM10 COMPANY
______ Willow Island. WV 26190________
PAY TO ----y----> 73o .}a /u /ic.___________
addr ess
DOLLAM
GJ v
CENTS
i
"*" <Qvt*c--- RUth Heilman
d el iv er t o Q
AuAAd* OF PtVMINT:" ' -
............ .... "" ------' i in .
The above employee has satisfactorily met all requ irements of the Educational
Assistance Proorag. Please reimburse this emolovee fo r RtEhQe^fanmWoWuntt/s/ho'wSn.
. R. D. Heilman
LJ
/(
G*J* stuny
R^iveo rV
SISNATURE
O AY K
GEN. LEM.
SUE. LEM.
OEPT.
NO---EMPLOYEE
NO.
EXPENSE CLASS
EMPLOY. NO-
CURRENT HO/YR.
SECONOART DISTRUUTION
AMOUNT
>
. * 4+K
CY-RI 006832
lv
$ h
/* in 0
4
o
V o V-S cQ
i
i
CY-RI 006833
W|-S1(8S(CY '.M3
payr o l l c hang e
"*
au t h o r izat io n
n e x t rnwt uNts SHomo wntcr s mo o t h 's s t a t u s a h s c h a n g s is ma o s
09/06/84
(>rftOT NO
6507
CO"**NT t OMltlOM
ACCO PPD (Q)
*l*Nt o* 0**<t
CHICAGO
0E* COOI
0420
OfRT *NO O* SCCOn
MPG.
{M*lOv({ NAME
S. TERZIC
02/30/40
CONf SERVICE OAT|
06/01/71
<0* r*UM
TECHNICIAN
L-7
ntUncrMu'Sn.
GnoR
2**WH*.I>W<iscoy
a k
wo .uww
vc*o.
.
lOC COM
097
PAYROLL lOCA'ON
W.I.
HlMPriON STATUS
m
i-nMi ITEM#
m? NON fKMPT
in MO
;i a d o n is s *s t
-0*<t a ODEESS C-t v A 5TATf
yn oi change
t n ew EMFVOYK
MtO (OnMftf MlO*n
TRANSFER
,a JO
MtOws
fMIC*** OAtf
E*P COM
s
n;<
MAf'AL 5
7M cm
SOC SEC NO
DEGREE A$ IS
^VRE COM
C'ttttM
> I
coil I wsc !!
9 ASSOC * t |Ch
I *s 1 MO
n
7 N.VfCN
DEGREE ma u#
DEGREE Rh o OTHER
1 US
w t ax
n !"; con i sue
* |TTH{ COU ! 0*4C A MO
STATUS
1l
1
S OVM
11 1
1 1
i <t
* *
Ot h e r
n; i
, J. 1
,,1
---------
*
Check and complfft appropriate $c#ron or stctions bilow.
CQmRa n * a n Q O'vii'O*
sr :
Man T 0* 0*1*1
'* I(WK VAST OAT* wOtVEO
NO <MRt
NT MS O-NO 1 MS
DfRT AMO 5 SfC'tOM
*r#ou ioc*nQN
3 SAUrr CHANGf
st at us c hang e
**ccOcCustWwUSHcfASnNotMNM
t e r min a t io n
AOCHTION
i REPLACE. AOV REEL
09/01/84
JOE Tiif
LAST OAr WORKED
VACATION RAV DUE
wr S r a t IM UEU OR NOT*!
AMD. CONTROLLER'S OR OTHER noumo AUTHOR*Ia Tk OM
AtfTHCEWO RV NAME OR EMPLOY* N*MO REPLACED
WIS
DAPS OATS
RRR NCSCNT SAUHV CHANCC
ROT.
RATING
___ EL
MO
(.AST SAW.*'
* 07/01/82
MO
j h 4*9 %)
\ o SUm
iR
in
LEVEL
EXEAiRTtON COM
r u mc t iOn
(EO
XI l(XfMRf 7 H EXEMRT
EL
CONTINUOUS SERVICE DATE
ItO
RICOMMINMO TOE REMEE
1 1 o
Ea s o n 10* t iEa mn aTiOn
1 DISCHARGEt r es ig n at io n -r e ntt o r r o et u mt y 7 ECSiGNAnON-EltSONM
4 fllAUMAHONMUTUAl a GRCEj MENT 5 LATCK OR ELIMINATION OR XX MILITARY SERVICE f RETIREMENT MATH 9 EXPIRATION OR CONT SERVICE CREDIT
LAST OATI WORCSO
REASON LIAVMO
LEAVE OF AtSCNCC
REINSTATE RtQM LEAVE OR ARSENCf
fv a l u a t io n SCALE A
ON LEAVE UNCI
REMARKS'
____ ao e
WITHOUT RAT
VARIATION t o BAREST POINT OR
GL -$202
14 MO INTERVAL
OERARTAIENTAL AND ONlNOMAi APPROVALSAND OATES
mattm
CY-RI 006835
ACT*0n 0AT|
CONTROL OROUR
FOR PAYROLL DEPARTMENT USE
owawjnoN
PAYROLL MUMRER
LOCATION COM
RfDMNCtCOM
DISTRIBUTION: WHITE--Original /BLUE--Piyrol/GREEN--ReOirvCANARY--Ptyrol/PINK--Return to Origjnator/GQLOENROO-WayM Pmoiml Mattm OegL
96 749-1095 Ho 11/73
PAYROLL CHANGE AUTHORIZATION
OArt
nCAAHO 06/10/83
'N
NEXT TH3CT LINES SHOUL0 BETLtCT EMPLOYtFS STATUS AFTM CHANGE IS MADE
e mpl o y ee n o .
6507
c o mp an y a DIVISION
ACCO PPD Q
PLANT OR OPMCI
CHICAGO
MPT COOC
0410
MPT ANO'QR SECTION
MFG.
FUNCTION COOC
EMPLOYEE NAMf
B. TERZIC
RACE-fEO
HtTW DATE
03/30/40
CONT SERVICE DATE
06/01/71
JOE COOt
JOE TITLE
TECHNICIAN
LEVEL
1-7
VBBBB
;
AMItKAM CTANAAUO CO SOUND UOO. N J
LOC COM
097
C^^(T2
w.r.
JOE STATUS
mas
EXEMPTION STATUS
ryr i c mp t | C I 3 NON EXEMPT
SBS5.R
243
A NO
2
COMPLETE NEXT TWO UNE5 FOB NEW EMPLOYEE TRANSFER BETWEEN PAY POINTS. AND PLANT EMPLOYEE GOING FROM HOURLY TO SALARIED STATUS
NOME ADORESS-STREET
SEX SOC. SEC Np.
OCCJNI-AS u
TYPE COOt
Cl^ZEN
HOME ADDRESS-CITY a STATE TYKOPCHANO*
ZIP COOC
1 1IT
MARITAL
2M
n J-?
' !''-! COU ;!
i!
! DISC j
!
0 ASSOC 1 T|Cw 7 N. TECH
2 HO
n
OCGRCfMA/LLl
ItYNi COU. 1 DISC III
!i
OEGREE PHO.OTMtR
TR }TVPf{ COLL. J OiSC
j!
j
3 LLl
J OVM OTHER
W *AX STATUS
1 S>
Chtck and comp/plp appropriate ipcfion or stcfions btlow.
NEW EMPLOYEE
IMIO COM/UIS 4 M10WI
COMPANY AND DIVISION
sr
PLANT 0* OFFICE
IP l(WH. UST Oa TI WORKED
"
NO CCmPT
s * **S JNO '*?
TftANSFEft
Msocwmfn mow)
MPT ANO Ot SECTION
PAYROLL LOCATION
3 SA1ARY CHANGC
07/01/83
STATLdHjjMAMOt
4RtCUSWCAT)QN <NSQ COMPLETE 4 lOW)
JOE TITLE CUT OAT WORMD
S t e r min a t io n
VACATION PAT OUt
WKS.
utup a t in
o p Nona
MQ
CONTlOUfin Of OTHER RtCMMD AUTHORIZATION
AunouEOtr
NAME Of EMPLOYER MMO REPLACED AootnoN
` Oi r epl ac e, a o v . tm.
WKS.
LEAVE OP ABSENCE
LEAVE Of ABSENCE EVALUATION SCALE A OCOflff
REMARKS)
ON HAVE SINO
OATS
POT. RATING_____
,m
PRESENT SAURY CHANGE
J4L m rr:o -%i
USTSAUI
04/01/82
M0
m
j 53o w t m a SaaOTiOn ?i o3iugvMf*Mrt
LEVEL
EXEMPTION COOC
FUNCTION
CEO
PAYROLL NO
r~~] MXEMPT | i 7-N/CXCMPT
CONTINUOUS SERVICE OAlt
RCCOMMfNOCO PORRCMNI
m >
RtASON FOR TtlMINATlON V RfStCNATtON-tlTTU OPPORTUNITY 3. RESIGNATION-PERSONAL
3. OISCHARGC 4 TERMINATION-MUTUAL AGREEMENT
5 LAYOPP OR CUMINATtON Of JOE 6. MILITARY StRVtCt 7. RtTlREMfNT
I. DEATH EXPIRATION Of CQNf. SERVICE CREDIT
i
|
a
| jJ
REASON ISAVINO JOE
QTfRMMATlON
LAST DATE WORKED
-
WITHOUT
..
n
PAY
VARIATION TO NEAREST POINT Of RANGE
___ QL MINUS m
15 M0 INTERVAL
0CPAI1MNTAL AND DMDQNAL APPROVALS AND OATES
PfRE Rti. OPT, APPROVAL A PATE
] CONTROL OROUP
FOR PAYROLL DEPARTMENT USE
PATEOUNUPOIE
lOCAnoNCoec
An
CONTROLLER'S APPROVAL A DATE
CY-RI 006836
ESwcNacoec
iOAYt coKtoing
uxAnQMCoot
ttMttwtttOOt
38 i<7a
PAYROLL CHANGE
Oa TR-
PREPARED
AUTHORIZATION
NEXT THREE LINES SHOULD REELECT EMPLOYEE'S STATUS AfTE* CHANGE IS MADE 2/23/81
EMPLOYEE n o
COMPANY i DIVISION
PLANT OR OFFICE
0f*T CCOE DIPT 4N0 OR SECTION
iMjtiCA* CYANAMlO CO
40U*0 UOQ M 1
:o o e
a >Ci.
Cn
*Ot tjty .51 CM*
6507
f u n c t io n COOt
;Oi CODE
ACC0-0CD CHICAGO
e mpl o y ee n a me
B.TERZIC
,OR TITLE
0410
RACE ISO
iEvi
MFG.
i 097
e.B.
UPTM DATE
-. :jCON*
C5 DATE i
'***VS |
..........
irr1,;
03/30/40 06/01/711 rri: si: l-Ti
SALARY RANGE
' 1 AC%* :**
243
2
t e c h n ic ia n
__tZ_j
>> HO.
-OmE ADDRESS-STRff? -OmE ADDRESS C'TV S $T*T|
TVPf OP CHANGE
EFFECTIVE OATf
SEX
ZIP COOf
i ! i-f
MARITAL STATUS > s
nil
SOC SEC so
* ;{ :s\-. j : sc
DtOM! ma .J
T!OM! "C Of **?*
: - *s> '
!
1(!1'*;111 :su !111 :sc
* , *vJ :cu J j-sc i * > - -= j 1 ;
OitWr and comp/ofo oppropnof* scMon or sec/ions celow.
l a s t DAY WORREO
5 t e r min a t io n
outv a c a t io n p a t
VMS. PAY IN UCUOP NOTICE
4
ApoinoH
!: REPLACE. ao v . ic pr .
MOl CONTROLUTS OR OTHER RfOUMfO AUIHORBAHQN
At/rxoRtao *r NAM* OR EMPLOYEE HMO REPLACED
WYS.
LEAVE Of AESENCE
REINSTATE PROM LEAVE OP AESENCE
EVALUATION SCALE *
ON LEAVE Sd
REMARK&
CONTINUOUS SERVICE DATE
ECO
OAYS DAYS
RECOMMENDCO FOR RfMIEE
"
3.Ma s o n FOR t er min at io n t. MSlGNAnON-MTTER OPPORTUNITY
2. RESIGNATION*PERSONAL
disc har g e
4. TERMINATION-MUTUAL AGREEMENT J, l a t OM OR El imin a t io n OF ;*
4. MIUTARV SERVICE t RETIREMENT I. DEATH 9 EXPIRATION OP CONT. SERVICE CMOiT
REASON LEAVING JOE
mTERMINATION
l ast dat e w o r xeo
'
n WITH PAY
J=L
VARIATION TO NEAREST *OlNT OP RANGE
________ fi.Lu.HjHm $7Q_
DEPARTMENTAL ANO OMMOMM AWROVAU ANO OATffi
~
t^STTn,
afcfcttfo
l
1
FOR PAYROLL DEPARTMENT USE
OATMunON
PAYROLL NMMRBft
^ LOCATION COOt
Cc o0nNt rTo#lol eurir'ss .awp proovv a.li ti rm. -f
I
CY_RI 006838
M90ENCE COOE
CYAMAMtO
Pinof Prints
PRESENT ADDRESS
CYANAMID EMPLOYEES SAVINGS PLAN
ENROLLMENT FORM
v* 3
raw LsewnoM u me owtv
1 * * c . >. ; : 4
... 7
SOCIAL SECURITY NUMBER
; ^ / , r-vo-
ITHIIT
tffooc C INI T| M.
!
t *t
OATE OP BIRTH
.^ -/ fJ
DATE OP EMPLOYMENT
/ L2 / 64
eo*
JL&JL
CODE*
WORK LDCATNJH . ****, t?C***9 CO WCt' i m
aj>
ENROL LMCMT OAT'E
. if.J.J_____ T CAW
-SHADED AREA TO BE COMPLETED BY COMPAHY-
To enroll in the Cyanamid Employees Savings Plan, this form must be completed and returned to your Personnel or Employee Benefits Department
I authorize the Company and/or the Plan Trustee to enroll me in the Cyanamid Employees Savings Plan, and thus:
A. Authorize a deduction from my pay amount ing to the following percentage of "earn ings": (Circle one)
2% 3% 4%/33ft
B. Invest my savings as indicated at the right:
Government Bond Fund. Fixed Income Fund Diversified Fund Company Stock Fund
g. 2. Sj 2-
.%
_%
-%
(Any combination of multiples of 10% which total 100%)
Unless I request otherwise, I understand that in the event of my death before termination of my employment, the full value of my
accounts will be used to purchase a full cash refund annuity for my spouse if I am married at my death. Otherwise, the full value
of my accounts will be paid in a lump sum to my estate.
^
(Check [ ] only on>
l accept the abot* terms. -
-. r/r.
JiavethAlWVrtue of my accounts paid in (ctrci on#) 60, 120, 180, 240, 300,
tw
I heredyrequsifcto have the full value of my accounts paid in a lump sum to:
Pegs- TEAXtC.-
ftoTHe*
i\a.kf
^ A ,1 lit-.
I understand that! may-change this payment arrangement at any time prior to my death while still employed and t4&V{ppn termination of my employment for any reason other than death, I will have to make a new election
regarding payment of my accounts.
I have received a copy o^ the prospectus relating to this plan. * : ,
nUi'Jjy
This form must be forwarded by the Personnel or Employee Benefits Department Representative to ensure receipt by the
Employees Savings Plan Supervisor, Wayne, New Jersey 07470, at least 10 days before the enrollment date on which you wish to join the plan.
REVIEWED BY:
.Vr
PAYROLLS
ItfffCI A#RIO VKO BY CMRLOVCK# SAVINA# ALAN SUYCRVISO* errccTtve a # a y t mi a b o v e imn d l l mc mt b a t s :
CY-RI 006839
SB 749*1095 Rr *. 11/72
PAYROLL CHANGE
PyRErP*A.RED.
AUTHORIZATION
f
*uM>o*omciNtXT THREE lists SHOUIP PSFltCT tMPtOYSFS STATUS AFTER CHANCE IS MADE ' W A//9
EMPLOYEE NO
COMPANY 4 DIVISION
OHT COM 0M NOO*SCT!ON
A 6507 ACCO-OCD CHICAGO 041 0
MFG,
FUNCTION COOE.
EMPLOYE* NAME
ttRTH OAff
I COmT SERVICE DATE
B.TERZIC
03/30/40106/01/71
JO* TITLE
AMERICAN CTANAMIO CO SOUNO HOOK H i
IOC COOi
;OCa'`On
097 B.B.
tEMPTlON STATUS
1-EltMPT
j h in*-T|M
2 *CM |l(AA*r
f o r wv
ull ONiv
243
TECHNICIAN
L7
M0.
COMP1ETE NEXT TWO USES FOR NEW EMPLOYEE TRANSFER BETWEEN FAY POin ITS, a n d PIANT EMPlOYEE GOING FROM HOURLY TO SALARIED STATUS
NOME AOORCSS-STRCCT HO#* AOORESS-OTY 4 STATE
TYPE OR CHANG*
IFFECTTV* DATE
SEX
ZIP CODE
1 1 w.......
MARITAL STATUS , . s
? M
n i:r
SOC. SEC NO
5EGREI AS IS
*Y*f COOE
cr :e s
- :
c o u . j o is c !i
1 ASSOC l *EC*
ES
; so
n
DCGREE-MA.U*
5SOME-PN OTHER
3 - Ul
A fU
YR. } t y p e| c o u
i OlSC.
YR jTYPEj cou ; DISC 4 MO
il i Li1...
i i
i1
3 DVU
mil 6 OTHER
Chick and complete opproprioft stcfron or stcfrons below.
. * **. ^ NO
NEW EMPlOYfE
TAUO COMFUTIA MIOM
COMPANY ANO DIVISION
NEW I
In
Hit*
I____I Mlj
PUNT OR OFFICE
IF RfMlRf. LAST 0ATI WORKED
THANSfEU
(AUO COMMIT! MLOW)
DEPT ANO-OI SECTION
AVROU LOCATION
D3) SAURY CHANGE
STATUS CHANGE OR
REOASStnCATION
5 TERMINATION
4
ADOmON
! REPLACE. Aov. am.
12/01/7*
LAST 0AV WORKED
outv ac at io n pay
o*WKS.
pay in uevj
Nona
MO. CONTROUm OR OTHBIREQUM0 AUTHORIZATION
AUTHORIZED IV
mmn a me o p e mp l o y *
r vl ac eo
WKS.
n*t.
POT. RATING
fX3l
PRESENT SAURY CHANGE
UST SAUR'
JUL
10/01/7E
h . M0
jn m
} VONT*< aRv mO't ON
J A5lul**A|P :('(*
> p:-*~*0!N*AC*UR.
> **CM'0U**
PAYROLL NO
CONTINUOUS SERVICt DATE
ECO
DAYS DAYS
RECOMMENDED FOR ICHIRB
im*" ru
JZLiSsEXEMPT EXEMPT
EL
REASON FOR TERMINATION 1. R*SONAnOM.*CTT*R OPPORTUNITY 2. RESIGNATION-PERSONAL 3. DISCHARGE
4. TERMINATION-MUTUAL AGREEMENT
5. LATOPF OR ELIMINATION OP JOE
A. MILITARY SCRVICt
7 RETIREMENT
I. DEATH
9 EXPIRATION OP CONT SERVlC* CREDIT
LAST DATE WORKED
REASON LEAVING JOR
'TERMINATION
'
lAVEOFASSBf
REINSTATE FROM LEAVE OP AUKS
EVALUATION SCALE 4 0
EUOOET
REMARKS.
ON LEAVE SINCE
LAST OATS WORKED
n~
C.S.C. EXPIRES
n
VARIATION TO NEAREST POINT OP RANGE
_____1/4 p l u s $1
CY-RI 006840
CONTROL GROUP
FOR PAYROU DEPARTMENT USE
PAYROU NUMMR
LOCATION COQf
RC90ENCC COOE
88 749*1095 11/72
RAYROU CHANGE AUTHORIZATION
NEXT THE LINES SHOULD PEFLECT EMPLOYEE'S STATUS AFTER CHANGE -IS MADE
,,
4/1B/79
AMERICAN CYiNAMt CO AOUNO I ROOK N i
EMPLOYS NO.
COMRANY 4 0N1SIOM
RUNT OIOWI
OERT CODE OERT a n O'OR SECTION
LOC COOC
Ra p r OU iOCa z -On
6507
f u n c t io n c o m
TOR coot
ACCQ-0CD
EMPLOYS NAM*
B. TERZIC
t o r imt
CHICAGO
0410
a c e ECO
LEVEL
MFG.
URTM DATE
03/30/40
Sa l ar y Ra n g e
CONT SERVICE ATf
06/01/71
097
B.B.
JOR s t a t u s
m i-me m 11 iiw
?*?MA7ION >fAUS
rr-i i !4em#y | \ 2 NON EXEMPT
2
TECHNICIAN
L7
ho .
COMPETE NgXT TWO UNfiS FOP NfW MPtOY TRANSFER STWN PAY POINTS. AND PUNT EMPIOYS6 OOin O ^Om HOURLY TQ $a ^a *;S0 s t at u s
HOA ApORCSS-STRCfT
SEX SOC SEC NO
DEGREE *S IS
*>** 'Z0(
' **N
HOME AOORESVCTTY 4 STATE t y p e oR Ch a n g e
!*Cnvt ATf
ns PR COOf ma r it a l
n
DEGREE MA/U*
' !"! COU ` CISC
i!
'
... 1 !
!
0IOREE *h o OTHER
assc: 1 *c** 2 n ?!C" 3 .<*
n
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NSW EMFtOYfE
: *UO COMMTt MHOW
|R WR* (.AST AT v,o<
g .
COMPANY AMQ DIVISION
RUNfoorce
t r an s f er
(AOO COMMIT!* MtOMfl
DEPT ANO-OR SECTION
RAYROU LOCATION
3 SALARY CHANGE
HCHANOI
sncAtiON
ia l s o c o mmu om
LAST DAY WOKCO
5 TERMINATION
VACATION RAY OUt
WK1 r a y *n u c u o r Nona
a CONTROLLER'S OR OTHER RfOUOW a u t h o r iz a t io n
wo.
AUTHORIZE RY NAME OP EMPLOYS MNO REPLACED
4 ni:W I I 3 AOV. WL
LAST OATS WORKED
LEAVE OP ABSENCE
REINSTATE PRQM l e a v e o r i mug
EVALUATION SCALE 4 PROMT
04/16/79
ONUAvtSMa
03/12/79
PEW. POT.
/ EATING
PRESENT SALARY CHANGE LAST SALARY CHANGE
JZL
Os,
J M(Y
/
c o n t in u o u s s e r v ic e ATI
RECOMMENOCO ROC RfMMt
>o *>
*
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IXEAARTION CODE
A**cu 'O
JZL i-c x c al r t 2M.tX(MR1
EL
REASON TOR TERMINAftON I. RESKSNATtON*SETTER OPPORTUNITY
7. RESKSNATION-RCRSONAI 3. CXSCHARGE 4. TERMINATION-MUTUAl AGREEMENT
J LARGER OR ELIMINATION OR JO*
6. mil it a r y SERVICE
7 RETIREMENT
l OEATH
9. EXPIRATION OR CONT SERVICE ;Dtf
REASON LEAVING JO* TERMINATION
'
LAST OA1 WORKED 03/11/79
n JZL
VARIATION TO NEAREST POINT OR RANGE
*
REMARKS*
REINSTATE FROM DISABILITY LEAVE OF ABSENCE.
M
CY-RI 006841
90 749^095 v 11/72
PAYROLL CHANGE
^ SSS
AUTHORIZATION 3/21/79n e x t THKtt WES SHOUIO XEHtCT tMHOVtt'S STATUS' AfT6 CHANGE IS MADE
e mpl o y ee n o .
COMPANY 4 DIVISION
PLANT OR OFFICE
DEPT COOC DEPT a n o OR SECTION
"\ AMNtCAN CYANAMJO CO EOUNO EROOK Hj
vOC COOC
>AOli iOC**'Cn
6507
ACCO-OCD
CHICAGO
0410
MFG.
097 B.B.
FUNCTION COOC
EMPLOYEE NAME
RACE. CEO
LIRTM OATS
COn T SERVICE DATE
<G* 5TAfyS
*i Em#'On STa 'u S
JOS COM
B. TERZIC
JOS TITLE
LEVEL
3/30/40
SALARY RANGE
6/1/71
mi 12nri c t impt
14
sON Ex e mpt
AC'UAI SALAR*
TECHNICIAN
L7
MHfc MO.
COMPLETE NEXT TWO LINES FQ* NEW EMPLOYEE TRANSFER BETWEEN PAY POINTS, ANO UNT EMPIOYEE GOING FROM HOURLY tO SALARIED $t a T'j $
HOME AOORCSS-STRCfT
SEX SOC 5EC NO
DEGREE-** SS
' "4
2
HOME aOORESS-OTY s s t at e TYPE Of c h a n g e
z ip COM
n;r
"R jTvPfJ COIL. { MC
1i ;
3 SSCC 1 *CCn 2 N 'EC-
r~i
MARITAL
DEGREE ma LIS
DEGREE Pn O OTh |R
3 US
STATUS , s
n
2M
*.
io -.....
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11 1 11
1 I 1
YR. jTTPEj COIL 1' ii ii
] 0'SC
2 {
5 5v m A OTHER
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Check and complete appropriate section or sections below.
S' j V:
j NEW EMPIOYEE (AI$0 COMPUTE * M iO*A
Co mp a n y a n O Div is io n
S'
l an t o * o f f ic e
M
NltC
<F REHiRf. l a s t Oa t ? w O*<?0 ;C Mil
2 t r ansf er
ALSO COMPUTE HlOW|
DEfr ANO OR SECTION
PAYROLL LOCATION
3 SAURY CHANGE
STATUSjjMANQi
4r c c u $Sh c a t io n ,AUQ COMPLETE EftOW
5 TERMINATION
JOS TITLE
LAST OAT WORKCO
VACATION PAY OUC WHS.
pay in utu o p Nona
Mft'_________ wg. CONTtOUCVS OR OTHER HQURO AUTHORIZATION
L
PERP. POT. RATING
PRESENT SAURY CHANGE
JZL
L
UST SAURY CHANGE
LEVEL
EXEMPTION COM
|------- 1 MXCmPT ! | 2-N.EXfMPT
*u n CT)On
a ICO
>*c*o* <>
j o n C*
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n
CONTINUOUS SCRVKE OATC
OATS
toer c c o mme n o e o
r in r i
.
*>
RCASON FOR TCtMINATTON
I. RESIGNATION-SETTER OPPORTUNITY 2 RfStONATION-PtRSONAl 3 DISCHARGE A. TERMINATION-MUTUAL AGREEMENT
S. UUOPP OR ELIMINATION OP >01 A. MILITARY SERVICE 7 RETIREMENT t. OfATH
9. EXPIRATION OP CONT SIRVtCE CRCOir
6
! - ao o it io m - r epl ac e. AOV. RCPl
AUTHORIZED r y NAME OP EMPLOYEE RUNG REPLACED
LAST OATC WORMS
lAVE Of ASSENCE
03/12/79
REINSTATE PROM IfAVf OP AlKHCf
EVALUATION SCALE A NQR|.
noM
03/12/79
o n l e a v e sect
RCASON HAVING JO*
*TERMINATION
to
04/30/79
(AST OATt WORKED
'
WTTH
jm PAY
C.S.C txrais
JZL
03/11/79
06/21/80
toVARIATION NEAREST POINT OP RANGE
REMARKS*
DISABILITY LEAVE OF ABSENCE WITH FULL PAY LESS WEEKLY BENEFITS.
DEPARTMENTALANO MVtNONAiAPPROVALS ANO DATES
CONTROLLER'S APPROVAL & CATC
CY-RI 006842
as 749-1096 Br. 11/7i
PAYROLL CHANGE AUTHORIZATION
iNtPlOYfl NO.
6507
pu n c t io n c o m
JOR COM
COMPANY A DIVISION
ACC0-0CD
PUNTOROPPia
CHICAGO
(MPlOYII NAME
B.TERZIC
JOR t it l e
t ec h n ic ian
0_SE> PREPARED
>10 CO AMERICAN C*ANAMI0 CO ftOUNO SROOK. H J
DEPT COM MPT ANO O* SECTION
0410 MANUFACTURING
IOC. CODE
097
a y #OU LOC*T:Cn
B.B.
RACE. CEO
l cvh
L7
HATH OATf
CONT SERVICE 0a T|
03/30/40 06/01/71
>OR STATUS
mss
EEEMPf'ON STATES
r2"i1 ***** |. I ? NON <X|NPT
SHIV,, M0.
o* giv USE ONyv
243
s'
2
COMPLETE NEXT TWO LINES FOR NEW EMPLOYEE TRANSFER BETWSEN PAY POINTS, ANO PUNT EMPLOYEE GOING FROM HOURLY TO SALARIED STATUS
HOME AOOHSS-STRtST NOME A00RCSS>C(TY 4 STATE
t ype o p c h an g e
5fWW| OAft
ZIP CODE
SEX SOC. SEC NO
0EGREE-AS IS
n
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1i S
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ma r it al
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ui
STATUS , s
Y. jTYPf} COU. i 0ISC.
Eli1 * ! ..................1 ..ml ... ......... '
r,
COU i OISC
- *0
1 : i . 2VM
11__________________________ _O_THER
CU
Check and compJtfo appropriate section or sections be/ow.
NEW EMPLOYEE .*LSOC0MftrTlOW|
c o mp a n y a n d Div is io n
nr w Hitt
| I
punt o r o pnc i
I c. I HlRg
Ip RCMlRe. IART 0AT| WORKED
t r ansf er 'Aoo co***** mo*>
DEPT AND OR SECTION
p a y r o l l LOCATION
J
f I
33 SAURY CHANGE
STATUS CHANOt a RKussncAnoM * tALSOCOMPURC*iOM>
TERMINATION
AOOinON
Di: REPLACE.
` ADV. HA.
10/01/78
j o * rmi
l a s t OAT WORKto
VACATION RAY 0U| WO.
PAY M Utu OP Nona ___ mo .__________ WCl_________OATS COMTROUfrS OR OTMCR PtOUIRRC AUTNORUAnOM
PEW. POT.
p r e s e n t SALARY c h a n g e
RATING______
__2ZL
> MO.
LAST $AIAk YCHANG
in
ISM
' j
jtn*rm
07/01/77
m
J O,,*:**( 4 UCKtlL ) *Ok* i3l*
*C**C-4*
LEVEL
EXEMPTION COOC
PUNCTION
1(0
*vtcu VO
(------ t MXEMPT 1 I e n c x c mp t
jn_
CONTINUOUS SERVICE 0AI1
RECOMMENCED POO REMtf
- -
REASON PO TERMINATION V RCSiGMATlON^SlTTfR OPPORTUNITY 2. RESIGNATION-PERSONAL i. OISCHAROC 4. TERMINATION-MUTUAL AGREEMENT
3. IAYQPP OR ELIMINATION OP j Q4
A MILITARY SCRVia 7 r e t ir eme n t 5. 0CATH
9. EXPIRATION OP CONT SERVICE CREDIT
AUTMORBC0 RY n a me o p vmom r o n o i p u o p
LAST DATE WORKED
REASON LEAVING IOR *TERMINATION
'
LEAVE Of ABSENCE
REINSTATE PROM LEAVE OP ANENCS
e v a l u a t io n s c a l e * otom
tUOOET
REMARKS,
ON LEAVE UNO
l ast o at e w o r ked
WITH
n PAY
jh
VARIATION TO NEAREST POINT OP RANGE
3/4 MINUS $38
6,
_j5CTNDAn
. -7
DEPARTMENTAL. ANO OMSttNAL APPROVALS ANO OATES
?
CONTROL CROUP
TOR PAYROLL DEPARTMENT USE
omtunoN
PAYROLL NUMRER
PtRS REL Ogt LOCATION COOt
CONTROLLER* APPROVAL S 0*1*
CY-RI 006843
RESIDENCE COOt
tor. n/7?
PAYROLL* CHANGE AUTHORIZATION
0A"5 PREPARED
Next THESE LINES SHOUU) EEHECT EMPLOYEE'S STATUS AFTEK CHANGE IS MADE
CMPlOTK NO.
r C0MMN1T 4 WVWOM
PLANT OR OfNCf
d e pt . coot d e p t . a n o 'O* s e c t io n
AMERICAN CY1NAMI0 CO 00*0 ItOQK. H i
a*TtoiV vOCa *'C*
OR OiV 05* ONLY
6507
h j n c t io m coot
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EMMOYttlUMt
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j?. r c r z ic
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HANUFACTURIMiL CCNT SERVICE OAT*
J33JL Q-C.UiHD aRQuis
X'.Mrno* STATyj
03-30-40
JO Eliflfr-Ql-71
5-T8MP
TEmPT
SC* *E*MT
* *l Sal ar y
j ZA3 * SC
_2______
TECK.
TECHNICIAN
JJL
mn
COMPLETE NEXT TWO UNftS FO* NEW mPUOYE TRANSFER BETWEEN FAY POINT?
NOME AOORfSASTRCfT
2CGRE! *S 5S
pso s t at u s
j %* "ODE |
h o me AOoacsAcmr 4 s t at e TYPE Of CHANG*
EPffCTIVf OAT*
! 1 n*. i--"e| con. | 3'sc. OE1 OREf**0-OTHER1 f* <l>Pf!i COLL )l DISC
07 'aSjCS-O* C 12 s-L3r?c* A5 -.`3
2 n'c I SA'**rAUXS
L i1 i; 1l 4 OTHER irujj1
Chock and complete appropriate section or sections below.
NEW EMFiOYEE (au o eoMAtn * Mtowt
COMPANY AND DIVISION
ar :
PLANT OS OfftCI
'* REHIRE. LAST OAT* <vQRKED
C :JW - ' -S
t r ansf er
t*uo coMMfit mowi
06FT. AN0>OR SCCTTON
PAYROLL LOCATION
3 SAURY CHANGE
STATUSjjMANOC
^ ttOASSmCATlON
S TERMINATION
07-01-77
IASI DAY WORKED
VACATION PAY DU*
wo. PAY IN UCU Of NOTICt
MO. CONTSOLUTS OR o t mr w q u mmi a u t mo s o a t io n
WKS.
_L~ PERF.
POT.
p r e s e n t Sa l a r y c h a n g e
RATING______
_rxi.,,
LAST SAI
Ul L
07-01-76
rn"L-MQ
,1,0
I O|tMOTWP* J KCHaS* J cM*O*M*euNOMu-
t *0460NArr
CONTINUOUS SERVICE DATE
ECO
DAYS DAYS
RECOMMCNOCO fOS ICMNG
1 [t o ring
n UXlMPt TN/EXiMPT
El
CASON FOR TERMINATION 1. RESIGNATION-SETTER OPPORTUNITY }. RESIGNATION-*RSCNAl
3. DISCHARGE 4 TERMINATION-MUTUAL AGREEMENT
S. lAYOff OR ELIMINATION Of JOS A mil it a r y SERVICE 7 RETIREMENT
I. DEATH 9 EXPIRATION Of CONT SERVICE CREDIT
NAME Of EMPLOYEE WHO MPUOD 1 - ao o t
3 REP14 J-AOV.
LAST DATE WORKS
LEAVE OF AESENCE
REINSTATE MOM tfAVf OP ASSBSCE
EVALUATION SCALE 4 C
OMUAWSMCI
REMARKS.
REASON LEAVING JOS
'TERMINATION
LAST DATE WORO
-
WITH
n PAY
C.S.C EXPIRES
HL
VARIATION TO NEAREST POINT Of RANG*
________________ 2Z3L ~
60
i
JpEERU'
ja 1L <-Ki&G&-LL
CY-RI 006844
/ . 't i " . j 1
tro iT iT T 'T iirn T rr^
- u .
CY-RI 006845
M>74f`>IOSS *. I*. 77
PAYROLL CHANGE AUTHORIZATION
CMPlOrCCNO.
6507
fuNaoNCOOt
JOS coot
* COMPANV4 0NISI0M
PUNT 0* OPPCf
AC C0-0CD
CHICAGO
EMPLOYEE NAME
B.TERZIC
JOS TITLE
TECHNICIAN
Difc*
PREPAMO
OEPT. COOC
0410
tfV*l
L7
OCPT. ANO. ORSCCTON
MFG.
CONT SERVICE DATE
03/30/40 06/01/71
SAURY RANGC
AMIKOM CYANAJA0 QQ OUNO MOOC. N. i.
IOC. COOC
097
JOS STATUS
r hnjtfip-ll.PStM Jr ACTUAL SALAS'*
B.B.
EXEMPT* STATUS 1 EXEMPT
1 2 NON EXEMPT
.h o .
W* MY VS OMIT
u. . C.
243
* *NO
2
COMPLETE NEXT TWO UNfS FOR NEW EMPLOYEE TRAMSFER BETWEEN PA,y POINTS. AND WANT EMPLOYES GOING FROM HOURLY TO SALARIED STATUS
SIX SOC SEC NO.
DEGREE AS/IS
TYPE COOE
CITIZEN
n*"
Y. TYPE* coa
0ISC 0 ASSOC. 1 TECH.
t-YfS 2 NO
n
n o Ex e mp t
h o me a o o ms s - crrr 4 s t a t e
IP COOC MARITAL STATUS , ,
n it
DEGREE MA Ut YR. {TYPE* COU. DOC
OEGME-PHO'OTHIR rt. TYPE* COU- DISC.
J-US
S-OVM 4. OTHER
W..TAX nu.
N Y R(S
0i.-N;Os
t y pe o p CHANGE
Check and complete appropriate section or sections below.
&33. SALARYCHANQE
5 TERMINATION
1ADO* ZMPM
3-40V.
LAST DAY WORKED
VACAfONPAVOUR
W*S> . PAYS* LRU OP Nona
MOL
coMraoucrso r o ihr r mo u n d aut ho r o at io m
AUIMORODIR NANOMMRtOTBM940 R
WKSk
LEAVE OP ABSENCE
otoMiaevAUMnON s c au
REMARKS.
ONISAMSMa
i i
CONTMUOUS SCCYCt OAft
HO
DAYS
MHMMCOMMCNOCO POft
DAYS
MASON FOR TCAMMATON
1. tmONATON-aCTTCROPPORTUNITY 2. ttSONAnON-PttSONM j, 0BQ4MQI 4. TCftMMATIOM*AlUTUAl a g r e e me n t 3. WTOPP OR SUMMATION OP JOR A MRITARt SHVia
7. MTBEMENT *. OEAW 9. EXPSIATON OP CONT. SERVICE CfEOR
REASON UAVUQJO#
TRRWMAnON
UST DATE WORKED
n
o.
n.
WITHOUT
a PAY
VARIATON TO NCAMST PONT OP RANOC
GLR PLUS $27
MRARTAMNTAl AMD OWRUOPU1 APPROVALS AM> OAIVt
HAMn H.
a w o v ma o a t i
CY-RI 006846
COMTROUCrS APPROVAL A OATI
COMTROl GROUP
FOR PAYROU DEPARTMENT USE
PAYDOliNUMfiR
M
stsecNacoec
!
B749-10 tftvill/72
PAYROLL CHANGE AUTHORIZATION
t&Ti WISD
AMERICAN CYANAMIO CO. IOUNO iROOK. N. 1.
e mp l o y e e n o .
4507
PUNCTION CODE
JO COOE
COMPANY * DIVISION
PUNT OR OPPICE
a c c o -o c n
CNICANN
EMPLOYEE NAME
B.TERZIC
JO* TITLE
TECHNICIAN
OEPT. CODE OEPT. ANO/OR SECTION
toe. CODE
PAYROLL LOCATION
0410
RACE/EEO
LEVEL
L7
MAN0FACTQRINR
057
BIRTH DATE
CONT.SERVICEOATE JO* STATUS
EXEMPTION STATUS
03/30/40 06/01/71
far-! i . p e r m 1* I-EXEMPT I* It .TEMP 1* 2-NON EXEMPT
SALARY RANGE
ACTUAL SALARY
985.00 pep NO.
COMPlETt NEXT TWO UNiS FOR NEW tMPlOYH TRANSFER SETWESN PAY POINTS. AND PLANT EMPLOYEE OOINO FROM HOURIY TO SAlARlEO STATUS
HOME ADDRESS STREET HOME ADDRESS CITY * STATS
TYPE OP CHANCE
EFFECTIVE DATE
SEX
n
ZIP COOE MARITAL STATUS, s
Em__, 2 - M
SOC. SEC. NO.
OEGREE AS t BS
TYPE CODE CITIZEN
DEGREE MA/Ll* YR. ,TYPEj COU. `DISC
Y*. (TYPfj COU. | DISC. 0 ASSOC.
!:
1 TECH.
2 - N/TECH. OEGREE PHO < OTHER 3 LIB
y r . {t y pe; cou. j oisc. 4 . MO
1 YES
n1-MO W/TAX st at us
{I i>
1 1 1 1 5 0VM
t
1*
1
_____ 1____ 1________ 1_____
6
OTHER
1s 2M
Chock and completo appropriate saclion or sections below.
NEW EMPLOYEE
ALSO COMPIITI t MIOW
NEW I------ 1 RE.
HIRE 1 I MIRE
COMPANY ANO DIVISION PUNT OR OPPICE
IP REHIRE. LAST DATE WORKED
t r ansf er *UO COmPICTI * MIOW
OEPT. ANO/OR SECTION
PAYROLL LOCATION
U. R. C.
243
P'R NO. 2
NO. EXEMP.
N. Y. RES. 0-NO 1-res
033 SALARY CHANCE 02/01 /7*
PROM
PEEP. POT. PATINO
II
p r es e n t Sa l a r y c h a n g e LAST SAURY CHANCE
ac"Tvwrrory SAURY CHAf Jctl
--------------ATorarAp(Br
nM r e c l a s s ?/1c a t io n Mta coMPtm t mam
5 TERMINATION
02/01/7%
DATE 10/01/72
PERN' O.
JO* TITLE
j LEVEL EXEMPTION COOE PUNCTION
TCCNNM;iAN 4E) L7 HLAST DAY WORKED
i -e x e mpt 2^NIEXEMPT_
CONTINUOUS SERVICE DATE REASON POR TERMINATION
nff
PAYROUNO.
3___
VACATION PAY DUE
ECO
WKS.
DAYS
PAY IN LIEU OP NOTICE
RECOMMENOEO POR RCHIRI
MO.
WKS.
DAYS *
1. RESIGNATION-SETTER OPPORTUNITY
2. RISIGNATION-PERSONAL 3. DISCHARGE 4. TERMINATION-MUTUAL AGREEMENT 3. LATOPP OR ELIMINATION OP JO* 4. MILITARY SERVICE
7. RETIREMENT 8. DEATH _____________ 9. EXPIRATION OP CONT. SERVICE CREDIT
CONTROLLER'S OR OTHER REQUIRED AUTHORIZATION
AUTHORIZED EY
t
NAME OP EMPLOYB ftEINO REPUCIO
JO*. TITLE
* (--------11 * A0OITION I 2 - REPLACE.
L
L_J 3 - ADV. REPt. SALARY
LAST OATC WORKED
S LEAVE OP AftSENCE
PROM
REINSTATE PROM LEAVE OP AESENCS
ok i Ia v e s in c e
REASON LEAVING JQ*
QTERMINATION
LAST DATE WORKED
n n.
WITH
nPAY
C. 1 C EXPIRES
j
h
w it h o u t PAY
EVALUATION SCALE * DEORtt
12 271 223
JUL li.
_UL
wooer
REMARKS)
OATC -2/Z-
VARIATION TO NEAREST POINT OP RANCt
4LR PLUS $15
411
EPARTMENTAL ANO DIVISIONAL APPROVALS ANO OATES
ik e s :
C^wiiWS APPROVAL * PATE
z:
CONTROL OROUP
FO* FAYROU DEPARTMENT UJSSEE (I
OISTRIEUTION
PAYROLL NUMASCIDR V
iiv
Jftdvf iLOCwtON epos *
CY-RI 006848
RESIDRNCf COM
PAYROLL CHANGE AUTHORIZATION
rs
NEXT THREE LINES SHOULD IeFLECT EMPLOYEE'S STATUS AFTER CHANGE IS MADE
Jf .
DATE PREPARED
9/1*/72
~)
AMERICAN CYANAAUO CO. ROUNO RtOOC N. i.
FOR WV. USE ONLY
e mp l o y e e n o .
a 6507
COMPANY 4 OIVISIOM
ACC0-0C0
l a n i OH OFfiCC
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HAC 6RE60R 0*10
MFC.
IOC. coot
097
p*T*OU LOCATION
M.
u. .c
2*3
FUNCTION COOE
Emp l o y e e n a me
B.TEftZIC
lOI TITLE
TECHNICIAN
l evel
EL7
ir t h d a t e
CONT. SttVICC DATE lot STATUS
EXEMPTION STATUS
03/30/*0 06/01/71 ring HH tasa,mn
Fm M0.
P/R n o .
2
COMPLETE NEXT TWO LINES PO Nfw EMPLOYEE THANSftt BETWEEN PAT POINTS, ANO PLANT EMPLOYEE GOING fOM HOUtlY TO SALAElEO STATUS
HOME A0DRESS. STREET
SEX
SOCSEC.NO.
OEORCE AS/BS
TYPE CODE
CITIZEN
NO. EXEMP.
HOME ADDRESS - CITY 4 STATE
' TYPE OP CHANCE
EFFECTIVE OAfE
Z*P COOE
n
e!HR
nk
Yt. jIVPEi COU. DISC
1i 11
1
o. ASSOC 1 .TECH. 2.N/TECH.
n
DECREE-MA/US
OEGREE PHO/OTHER
3. US
RACE
y r . .t y pe; c o u . - oisc y r . ;rYPc; cou. ; d is c 4.MO
[!' '
!
i i SOVM i i 6 OTHER
__________________ _____________
Ctiedf ond comp/eTe appropriate section or sections below.
n
N. Y. RES. f.!8
* 3
TERMINATION
LAST DAY WORXEO
CONTINUOUS SERVICE DATE
v a c at io n PAY DUE,
WKS. pav in l ieu o f n o t ic s
MO.
WKS.
CONTROLLER'S OR OTHER REQUttfO AUTHORIZATION
M. P. U. NO.
OAVS r e c o mmc n o c d f o r RCHIRI
OAVS
REASON FOR TERMINATION
1. RESI0NAH0N4CTT1R OPPORTUNITY 2. RESIGNAnON.PCSONAl 3. DISCHARGE
A tttMINAllOtAMUrUAl AGREEKNl i. LAYOFF OR ELIMINATION OF JOR A mil it a r y s e r v ic e 7. RETIREMENT
A DEATH
f. tXPMATION OF CONT. SERVICE CREDIT
1-aAOOOOIImON
2-RREEPPULACE. 3-AOV. EFU
LEAVE OF ABSENCE
REINSTATE PROM LEAVE OP ABSENCE
AUTHORtZEO it_______________ NAME OF EMPLOYEE KINO REPLACED
SALARY
*___
JOR TITLE lAit OAll WORMEO
ON LEAVE SINCE
OAfE
REASON LEAVING JOR | ~~~) t e r min a t io n TO
LAST DATE WORKED
t r ansf er
INCLUSIVE
nw
C.S.C EXPIRES
EVALUATION SCALE 4 DEGREE T.1 T.R
REMARKS:
M0CET
- $52 8/72
VARIATION - 2/3 FT* MIMS $5
PROMOTION
n WITHOUT PAY
t o t al
CONTROL CROUP
| DISTRCU1ION
1
PAYROU NUMBER tf
LOCAOdNCDM
CONTROLLERS APPROVAL 4 DATE
CY-RI 006849
RESIDENCE COOE
PAYROLL'CHANGE .
O
AUTHORIZATION
n e x t t h p e e tiwes^Hmo*w>itcr e mu o y e t s iutu$ a f t ec h a n at is m*o e
''1 " NW
6/4/71
AMERICAN CTANAJNO CO. OUNO MOPC N. i.
EMPLOYEE n $.
A 6507
FUNCTION COOC
C600
joecooe
TECH
COMPANY 4 OlVISlON
UNT OR OFFICE
ACC0-0C0 HAC GREGOR
EMKOrte n a me
B.TERZ1C
j o * t it ie
TECHNICIAN
DEFT. C00
6650
MPUIINE
25
LEVEt
(pL7
OEPT. ANO/O* SECTION
IOC. COOE
FAYEOU LOCATION
MFG.-- INTERNED.
097
B.B.
*TH OA1E
CONI SEEVICE DATE
03/30/40 06/01/71
JOE STATUS
nine
EXEMPTION s t a t u s I 2 I ^KSn e x e mp t
SAUEY EANOE
ACTUAL. SAU*Y
' fiBBBMM M"
COMPLETE NEXT TWO LINES FOt NEW EMPLOYEE TAN5FE EETWEEN Pa y POINTS, AND PUNT Emp l o y e e GOING FPOM NOUElYTOSAi
st at us
HOME a o o r e s s . s t r e e t
SEX
SOC SEC n o
j L
DEGREE - AS/IS
TYPE COOE
CITIZEN
16 NO. BR0A0VIEV
NOME AOORESS - CITY A STATE
C LOMBARD, ILLINOIS
' ' .w k ; coil. . d o c .
m* ^_______!!
ZIP CODE SI
jDEGREE * MAULS
YR. .IYPE; COL- DISC,
DEGREE * PHO/OTHEt TR. .TYPE; COU. DISC
mil60148
||
; i >i
i i
0-ASSOC I. TECH. J.n /TECH. 3.111 4.MO J.OVM
4. OTHER
mUS
RACE
P1
TYPE OF CHANGE
EFFECTIVE DATE
Check and complete qpproprioTe section or sections below.
NEW EMPIOYEE
Df *MJO COwMI*
06/01/71
HO. car
IF REHIRE, l a s t Oa TE WORKED
NO. EXEmP.
01 N. Y.RES.
0?:?8
COMPANY ANO DIVISION PLAN' C* CF*ICE
t r ansf er <SOCOKCt|*WtOW
DEPT. ANO/O* SECTION
DEPi CODE
PAYROLL LOCATION
3 SAURY CHANGE
STATUS CHANCE
4 REClAS&tCAflOM
AiMeOMwmtHtow
t e r min a t io n
_z.
PfRF. POT. r at ing
PRESENT SALARY CHANCE
-SA*LA*R*Y&&
LAST SAURY CHANGE
joimU FROM
l ast o av w o r ked
JL
DATE
LEVEL
CONTINUOUS SERVICE DATE
VACATION PAY OUE ,
M. P. U. NO.
WHS.______________ DAYS PAY IN LIEU OF NOTICE
MO. NKS.
PAYS
RECOMMENOCD FOR REHItg
n^o
EXEMPTION COOC
J A0WVE4H*
HCIliH *40Ml MOW CRUMMil
FUNCTION M.P. U.NQ.
f-! I4XEMPT 1 1 ZN/EXEMPT
SEASON FOR TERMINATION
1. RCUGNAnOMRCTTCB OPPORTUNITY 2. RESIGNATION*PERSONAL 1. OtSCHAROE 4. TERMlNATION.MUTUAL AGREEMENT 5. LAYOFF OR ELIMINATION OP JOi A MIUTAtV SERVICE /.RETIREMENT 4 DEATH * e x pir a t io n o p com. s e r v ic e c r e d it
Q
CONTROLLER'S OR OTHER REOUIRCO AUTHORIZATION
AUTHQRTZIQ >Y_____________________________ NAME OF fMPLOYH KING REPLACED
JOR TITLE
I.AAODODI1ITION 2-RtfEPPLliACE.
3-AOV. RCPE.
SALARY
LASlbAil WORKED
LEAVE OF ABSENCE
$________
r ein s t at e f r o m LEAVE Of ABSENCE
EVALUATION SCALE A OEGRtt
REMARKS?
FROM ON LEAVE SINCE
Wa So n l e a v in g | | t e r min a t io n
LAS? DATE WORKED
'
nsyINCLUSIVE
C. S.C EXPIRES
l evel
n WITHOUT PAY
T-2 *2/12/6% FOR TINE ELI6I0ILITT TOWARD BENEFIT PROGRAH.
I
DEPARTMENTAL ANO DIVISIONAL APPROVALS ANO OATES
(y \
T CONTROL GROUP
g%T<k tAA,
FOR PAYROLL DEPARTMENTTUuSsI ar
OISTMUTION
5STTPAYROLL NUMBER
CONTROLLERS APPROVAL A_DATE
CY-RI 006850
RESIDENCE CODE
