Separation Notice

Date*

Date

Employee Name*

First Name and Last Name

Employee Email*

example@example.com

Employee ID#

Last day worked*

Date

Eligible for rehire?*

Lay off (check box)

Job completedReduction in forceOther

Voluntary Quit (check box)

Permit not renewedTo seek other jobPersonal Reasons

Discharge (check box)

Comments:

By signing this document, IEmployee Name am saying that I am free from injury/illness as I separate employment with APi, Inc. d.b.a. APi Construction. I also say that I have compliant with all of the Company’s policies and procedures, returned all company assets given or loaned to me, and followed all reporting protocols required by the Company. I separate my employment in good physical condition and have reported all incidents, near misses and / or illnesses to my immediate supervisor. Finally, I understand that a positive drug or alcohol test received by the Company post-separation is considered just cause for my discharge and my Separation Notice will be amended.

Employee's Signature

No Employee Signature

Employee refused to signEmployee was unavailable to sign

Supervisors Printed Name*

Supervisors Signature*

Supervisor's Email*

example@example.com

Date*

Date