State Work-Study Employer Information Change Request

Employer Name (required)
Employer Federal Id Number (required): Business name and Federal Id number must match current State Work Study contract.; Employer Information; This form cannot be used for a Federal ID number change. A new contract must be submitted to the school.
New Employer Name
Telephone Number (required): () - -
New Contact Person
New Address
Date Changes Take Effect: / /; Pay Rate Information; The HECB reviews pay ranges that exceed $25.00 per hour. The wages need to be comparable to what they would pay a non-work-study student performing the same job duties. This form cannot be used if the job title or job duties change. A new job description must be submitted to the school.
Name of Student's School
Position Number
Job Title
Old Pay Range: $ to $
Ending Date: / /
New Pay Range: $ to $
Beginning Date: / /
Comments: Please type your name below to represent your authorized signature.
Employer Signature
Current Date: 5/23/2012