Request for Temporary Agency Worker (HR Form 109)

Underline One: Classified, Confidential, Administrative, Other

Job Title ___________________________________ Grade _____

Cost Center Name ___________________________________ Location _____

Budget Expense Code __________________________

Dates Needed: Starting _______________ Ending ________________

Number Needed _____ Working Hours ________ _____________________

Worker(s) will report directly to which supervisor? _________________________

If new position, has the Job Description been approved? ____ Part-time? ______

Please attach a job description for all requests so that the Human Resources Office can ask for an appropriate worker. Thank you.

Temporary Replacement for Whom? _____________________________________

Reason for Replacement __________________________________________

Name Date

Requested by ________________________ ________________

Approved by ________________________ ________________

Senior Officer ________________________ ________________

Budget Verification ________________________ ________________

Human Resources Officer ________________________ ________________

President __________________________________________

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To be completed by Human Resources Office

Agency ________________________________________________

Date Started ________________________________________________

Wage Rate ________________________________________________

Name(s) of Temp(s) ________________________________________________

(8/11/03)