Separated Employee Information

Separated Employee Form
Please fill out and submit this form to the IT department. This will allow us to ensure all recently separated city employees are removed from our systems.
Separated Employee Name*

First NameMiddle NameLast Name
Department*
Date of Employee Separation*

MonthDayYear
Date
Group Email Removal
Select the email distribution group separated employee should be removed from.
IT equipment issued to employee must be returned to the IT department.
Door Access FobiPhoneiPadLaptopMobile PrinterOther
Name of supervisor submitting this form.*

First NameLast Name
Email of supervisor submitting this form.*
example@example.com
Additional Details
Should be Empty:

Separated Employee Form