Form Center

Additional Pay Request

2. Routed to Operations Chief, CC'd to Supervisor
   CC'd Recipient: This Form is For Awareness Only, No Further Action Required.

   CC'd Recipient: This Form is For Awareness Only, No Further Action Required.

4. Please Refer to Appropriate SOP for Specific Pay Information
   SOP Section 2 - (200 Series) Position Descriptions

5. Please Refer to Appropriate MOU for Specific Pay Information
   NCFA MOU

7. Employee Information:

9. First Name*

10. Last Name*

12. Employee ID*

13. Date*
    Date

15. Check All That Apply

17. 1. Hazardous Materials Team
    2. Infection Control Officer
    3. Shift Fire Investigator
    4. State Fire Chief/Chief Fire Officer
    5. State Fire Officer/Company Officer
    6. Tactical Medic
    7. Technical Rescue Specialist-USAR
    8. Water Rescue Technician

18. 1. 30 Semester Units
    2. 40 Hour Assignment
    3. AA Degree
    4. Apparatus Specialist
    5. BA Degree
    6. Bilingual Pay
    7. Captain-Paramedic Assignment
    8. Fitness Coordinator

20. Reason For Request*

22. Please provide supplemental documentation separately, e.g., college transcripts, degree for educational pay, copies of MQ requirements for each specialty pay, or copies of course completion certificates for officer courses. Supplemental documentation must be attached at the time of form submission.

    Please provide supplemental documentation separately, e.g., college transcripts, degree for educational pay, copies of MQ requirements for each specialty pay, or copies of course completion certificates for officer courses. Supplemental documentation must be attached at the time of form submission.

24. Supplemental Documentation #1

25. Supplemental Documentation #2

26. Supplemental Documentation #3

28. Supplemental Documentation #4

29. Supplemental Documentation #5

30. Supplemental Documentation #6

32. Your Supervisor *
    -- Select One --Administrative Battalion Chief BerensBattalion Chief CorteseBattalion Chief GilbertBattalion Chief RhodesCaptain BaraccoCaptain BecerraCaptain BeckerCaptain BurgessCaptain CaldwellCaptain ChamnessCaptain CronbachCaptain CroweCaptain D'AngeloCaptain DavisCaptain DombrowskiCaptain JonesCaptain KochCaptain LangfordCaptain MortimoreCaptain OlivaCaptain VoglerGreg FortuneShuree Egloff

    You Supervisor Will Receive This Request

34. If approval is received, the form will be forwarded to Fire Administration, and the adjustment in pay will take place at the beginning of the next pay period. No change in pay will occur until this procedure is complete and a Personnel Action Form (PAF) has been submitted to and processed by the Finance Department.

    If approval is received, the form will be forwarded to Fire Administration, and the adjustment in pay will take place at the beginning of the next pay period. No change in pay will occur until this procedure is complete and a Personnel Action Form (PAF) has been submitted to and processed by the Finance Department.

Leave This Blank:


35. 1. Receive an email copy of this form.
36. Email address

    This field is not part of the form submission.

37. Submit

* indicates a required field