Employee Separation Form
Fill out immediately. Once submitted, this form goes directly to Leanne Clark, Kacey Hijmans and Lauren Aiello.
Date of Notice
*
-
Month
-
Day
Year
Last Day Worked
*
-
Month
-
Day
Year
Employee Name
*
First Name
Last Name
Department Number
*
Reason for Separation
*
Termination
Voluntary Quit
Leave of Absence
Lay-off
Illness/Injury
How are they collecting their final paycheck?
*
Pick-up at Bailey Hill
Pick-up from Manager
Mailed
Direct Deposit (5th and 20th only following final day worked)
If "Mailed" is selected, please provide the most accurate mailing address.
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Your Name
*
First Name
Last Name
Manager Signature
*
Today's Date
*
-
Month
-
Day
Year
Submit
Should be Empty: