Name:  ____________________________________________________________________________________________

Department:  ______________________________________________________________________________________

Term:    Start Date:  ___________________________________  End Date:  ___________________________________

Change in Load:      Teaching:  ______________     Research:  ______________    Service:  _____________

Salary Distribution:

1.    Account:  ____________________________________________________     Amount:  _______________________

        Start Date:  _____________________________________   End Date:  ____________________________________

2.    Account:  ____________________________________________________     Amount:  _______________________

        Start Date:  _____________________________________   End Date:  ____________________________________
 

 Amount of Stipend, if applicable:  ____________________________________________________________________

1.    Account:  ____________________________________________________     Amount:  _______________________

        Start Date:  _____________________________________   End Date:  ____________________________________

2.    Account:  ____________________________________________________     Amount:  _______________________

        Start Date:  _____________________________________   End Date:  ____________________________________

Approvals:

Signature:    _____________________________________________           Date:  ________________________________
                        Chair

Signature:    _____________________________________________           Date:  ________________________________
                        Dean

Signature:    _____________________________________________           Date:  ________________________________
                        VP Academic & Provost
 

Distribution:  Human Resources,  Finance,  Office of Research, Dean, Chair

Finance
December 2009