Fillable Staff Separation/clearance Form printable pdf download

Associated Students Inc. , California State University, Northridge

Staff Separation/Clearance Form

COMPLETED BY DEPARTMENT OFFICE - The Department Designee is responsible for ensuring that the

Separation/Clearance process is properly completed for each separating employee. After completion, this form should

be returned to Associated Students Human Resources Office with authorized signatures.

Employee’s (Last name):

Employee’s (First Name)

Middle Initial

Last Day physically worked:

First Day of Separation Status: (next business day)

First Day Of Retirement Status: (If

Applicable)

Department Name:

Separation Reason:

Eligible for rehire: [ ] Yes

[ ]No

End of Semester [ ] Graduated [ ] Resigned [ ] Quit [ ] Terminated [ ]

Unknown [ ] Temporary Appt [ ]

Employee Status: Staff [ ]

Employee Status: Student [ ]

* Request for Vacation to be paid on check date ____/____/____.

EMPLOYEE CLEARANCE – Department Designee is responsible for clearing employee of all outstanding

obligations within the department on campus. Departments may have additional clearances which may be required for

record keeping. Additional required clearances should be listed below.

Campus Required Clearances:

Cleared

Dept. Issued Required Clearances:

Cleared

Office Keys/Key Cards/Locks Returned

Returned

A.S. Equipment Returned:

Lost

(Computers, Cell phones, Pagers, etc.)

ITR-Computer Access

acctmgr@csun.edu

Cancellation of Signature Authority

(accounts, passwords…)

Additional clearances:

Other:

Mailing Address – This will update your AS Employment Record with Associated Students Human Resources and

Payroll information pertaining to your Tax Statement (Form W-2) and any final warrants to be paid out:

(Number, Street, Apt. No.)

(City)

(State)

(Zip Code)

I certify that I have returned all Associated Students property and paid all debts. I hereby tender my resignation from Associated Students

at California State University Northridge. This resignation is executed by me freely and of my own free will, and is not given by reason of

any threat, force, duress, or any undue influence by any person or persons.

Employee

Signature_________________________________________________________________________

DEPARTMENT CERTIFICATION AND APPROVAL – Department Designee’s signature must be on file in

Associated Students Human Resources Services to be valid.

Department Director/

Print Name

Ext:

Date:

Supervisor Signature

Comments:

OFFICE OF HUMAN RESOURCES – This form and attachments are to be given to the Associated Students Human

Resources Office. All clearances should be initialed and Section C signed by authorized person before HR

authorization is complete.

Forms Issued:

Separation Checklist:

COBRA Form and Information

Completed Report of Staff Separation/Clearance Form

Clearance form is complete and has necessary signatures.

Separation forms processed to Associated Students Human Resource

I will verify that clearance is complete and has the proper authorization.

Human Resource Signature:____________________________________________________Date:________

Staff Separation/clearance Form

Related Articles

Related forms

Related Categories