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CHANGE OF PAY STATUS This form is only to change pay status. If an appointment change is part of the pay change, then the Appointment of Licensee (L1) form is required. 1. TCLEOSE A g e n c y N u m b e r 3. TCLEOSE PID 2. A p p o i n t i n g A g e n c y 4. Last Name 5. First Name 6. M.I. 7. Suffix (Jr., etc.) Required APPOINTMENT INFORMATION 13. Date Appointed 14. Date Pay Status Changed 15. Current Pay Status: (CHECK ONLY ONE) Full Time - Regularly work 32 hours a week or more and p.

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