Separation Notice

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SEPARATION NOTICE
(revised 11-29-01)
DATE:
PLEASE SEND A COPY TO CORPORATE WITHIN 24 HOURS OF SEPARATION. THANK YOU.
NAME
LAST
FIRST
INITIAL
SOCIAL SECURITY NUMBER
ADDRESS
STREET
CITY
STATE
ZIP
BRANCH NO. AND LOCATION
SEPARATION DATE
FIRST DAY WORKED
LAST DAY WORKED
LAST POSITION HELD
RATE OF PAY
LEFT ON OWN ACCORD
3 DAYS UNREPORTED ABSENCE (GIVE DETAILS UNDER REMARKS)
VOLUNTARY QUIT – REASON UNDETERMINED OR UNKNOWN
TO ACCEPT OTHER WORK
ILLNESS OR INJURY
MARRIAGE, FAMILY RELOCATION, OR OTHER PERSONAL REASON
TO ATTEND SCHOOL
MILITARY SERVICE
FAILED TO RETURN FROM LEAVE OF ABSENCE OR FMLA
OTHER (GIVE DETAILS UNDER REMARKS)
DISCHARGED (EXPLAIN IN DETAIL UNDER REMARKS AND GIVE DATES OF WARNINGS,
PERFROMANCE COUSELING, AND PRIOR VIOLATIONS
IMPROPER CONDUCT IMPACTING OPERATIONS (MAY INCLUDE CONDUCT OUTSIDE OF NORMAL WORK
HOURS)
DISHONESTY (SIGNED STATEMENT REQUESTED)
UNREPORTED ABSENCE (SHOW DATES UNDER REMARKS)
FREQUENT TARDINESS (SHOW DATES UNDER REMARKS)
FIGHTING OR THREATING OTHERS ON COMPANY PROPERTY
FALSIFIED APPLICATION
POSSESSION OF DEADLY WEAPONS ON COMPANY PROPERTY
POSSESSION, OR USE OF INTOXICANTS OR ILLEGAL DRUGS WHILE ON COMPANY PROPERTY
DISRESPECT OR DISCOURTESY TO CUSTOMERS OR STAFF FORCE EMPLOYEES
THEFT (SIGNED STATEMENT REQUIRED)
OTHER (GIVE IN DETAIL UNDER REMARKS)
(Accrued personal time is not paid at termination -per
REMUNERATION PAID AFTER SEPARATION
policy)
PAY IN LIEU OF NOTICE: AMOUNT
SEVERANCE PAY: AMOUNT
NOTE: REMUNERATION AFTER SEPARATION MUST HAVE APPROVAL OF REGIONAL MANAGEMENT
OR EXECUTIVE STAFF
MAIL FINAL CHECK TO:
ADDRESS
STREET
CITY
STATE
ZIP
REMARKS:
MANAGER’S SIGNATURE:

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