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2. Routed to Operations Chief, CC'd to Supervisor
   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

    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. Company Officer Coursework ($50 2 Year Term)
    9. Company Officer Certification ($100 Pay No Term)
    10. Fitness Coordinator
    11. Hazardous Materials Team
    12. Infection Control Officer
    13. Shift Fire Investigator
    14. State Fire Chief/Chief Fire Officer
    15. Tactical Medic
    16. Technical Rescue Specialist-USAR
    17. Water Rescue Technician
17. Reason For Request*
19. 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.
21. Supplemental Documentation #1
22. Supplemental Documentation #2
23. Supplemental Documentation #3
25. Supplemental Documentation #4
26. Supplemental Documentation #5
27. Supplemental Documentation #6
29. Your Supervisor *
    -- Select One --Operations Division Chief BerensBattalion Chief CorteseBattalion Chief GilbertBattalion Chief RhodesAdministrative Battalion Chief BecerraCaptain AimarCaptain BaraccoCaptain BurgessCaptain CaldwellCaptain ChagonjianCaptain ChamnessCaptain CroweCaptain DavisCaptain DombrowskiCaptain GenaroCaptain JonesCaptain KochCaptain LangfordCaptain MortimoreCaptain OlivaCaptain UlitinCaptain VoglerGreg FortuneShuree Egloff

    You Supervisor Will Receive This Request

31. 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:


32. 1. Receive an email copy of this form.
33. Email address

    This field is not part of the form submission.

34. Submit

* indicates a required field