SEI/Aaron's, Inc.3108 Piedmont Road, Suite 202

Atlanta, Georgia 30305-2377 / (404) 495-9707

Personnel Action •••• Status Change

� Type of Change � � Effective Date __________________

Employee Name ___________________ ________________________ ____ Store # _______________ Last First M.I.

Home Address______________________________________________________________________________

City ________________________ State ________________ Zip __________ Social Security # _____________________ Exemptions Federal _________ State __________ Position ________________________________

�� � � � � � � Rate/Salary Special Instructions _________________________________________________________________________

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Position ____________________ ___________________

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Rate/Wage $___________ per _____ $__________ per ______

Termination ____________________ Last day worked Reason for Termination

(Be specific) ____________________________________________________________________________________

Employee Purchase _____ � � Amount to deduct $ _________________________ Authorization Approval #1 Authorization Approval #2 Print Name ____________________________ Print Name ____________________________ Signature ____________________________ Signature ____________________________ Title ____________________________ Title ____________________________