Termination Form
Employee Name
*
Last Name
First Name
Full Social Security Number
*
Date of hire
-
Month
-
Day
Year
Date
Last day worked
*
-
Month
-
Day
Year
Date
Netchex/Punch Report
Date of termination
*
-
Month
-
Day
Year
Date
Rate of pay
Store number
*
Today's date
-
Month
-
Day
Year
Date
State ID number
Company name
AD Email
*
example@example.com
Location Email
*
example@example.com
Completed by
*
First Name
Last Name
Phone Number
Reason for termination
In addition to checking a reason for termination, please provide a full explanation in the space below.
Voluntary
*
[] Quit, without notice or reason
[] Another Job
[] Relocation
[] Personal Reasons
[] Work Schedule
[] Return to School
[] NO CALL/NO SHOW: Must provide
dates of missed shifts below
[] Retirement
[] Refused Suitable Work
[] Leave of Absence - Did not Return
[] Job Eliminated or Changed
[] Other
Involuntary
*
[] Absenteeism
[] Insubordination
[] Violation of Company Policy
[] Cash Shortages
[] Intoxicated
[] Falsification
[] Tardiness
[] Unsatisfactory Performance
[] Refusal to Follow Instruction
[] Job Eliminated or Changed
[] Sleeping On The Job
[] Other
[] N/A
**Please provide specific dates and details of the incident. Prior write ups should be sent in along with this form.
NCNS Date 1
-
Month
-
Day
Year
Date
NCNS Date 2
-
Month
-
Day
Year
Date
NCNS Date 3
-
Month
-
Day
Year
Date
Leave of absence
[] Family Medical Leave Act
[] Military Leave
[] Personal Leave
**Not to exceed 30 days
**Must be coordinated with Human Resources***
Picture of resignation
File Upload
Browse Files
Cancel
of
Explain reason given above in detail
*
Is employee eligible for rehire
*
Yes
No
If not eligible or only under certain conditions, explain:
Termination tasks competed
*
Term in Aztec
Term in Rosnet
**FOR OFFICE USE ONLY**
Termination of benefits as of
Benefits selection
Health ______ Dental _____ Vision _____ STD ____ LTD ____ Basic Life _____ Voluntary Life: EE Only ______ ES ______ EC ______
Submit
Should be Empty: