Manager Status Change Form

Form submitted by *

Employee status change forms must be submitted by managers on behalf of the employee named in the form.

Today's date *

Purpose of this form (check all that apply) *

Explain "other" from section above *

Employee name *

First

Last

My name is *

First

Last

I don't generally use my first name. Instead, I prefer to be called

My address is *

Address Line 1

City

State

Zip Code

My new address is *

Address Line 1

City

State

Zip Code

My social security number is *

My email address is *

My phone number is *

This is a *

Mobile phone
Land line

My COVID vaccination status *

I'm fully vaccinated
I'm partially vaccinated
I plan to get vaccinated
I do not plan to get vaccinated

I expect to be fully vaccinated by this date *

An exact date isn't necessary. Use your best guess.

I was offered this position by *

I've been hired - or re-hired - as *

Manager

The pay I've been offered as manager is *

I plan to start work at the Brewery on *

I was referred for this position by this current Portsmouth Brewery employee

First

Last

My current pay rate is *

My new pay rate *

My new pay rate takes effect starting *

Employee's last day on the job. *

Date of termination *

Reason for termination *

Eligible for re-hire? *

Yes
No

Eligible for re-hire? *

Yes
No

Eligible to collect benefits in final paycheck? (Full-time benefits-eligible employees only) *

Yes
No
Not sure

New employee name *

First

Last

Effective date of name change *

Leave of absence begins on *

And ends on *

Eligibility to work *

I attest that I am eligible to work in the United States, and I understand that I must complete Form I-9, including showing required identification to Brewery management, before I begin my first shift.

Agreement *

I attest that to the best of my knowledge the information I have provided on this form is accurate and I agree to the wage rate(s) listed herein.

Employee signature *

Use finger to sign on a mobile device, or the mouse on a desktop computer.

Manager signature *

I have reviewed the wage rate(s) listed above and attest to its/their accuracy.

Photo of new employee

Click or drag a file to this area to upload.

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