Charter Inc. Employee Resume Template
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1
2HQ F 3293.1 (1-12)
All Other Editions are Obsolete
U.S. DEPARTMENT OF ENERGY
HEADQUARTERS EMPLOYEE FINAL SEPARATION CLEARANCE
Form should reach the Office of Security and the HQ Servicing Human Resources office on the last day of active duty.
PART I – TO BE COMPLETED BY EMPLOYEE OR OFFICE TO WHICH THE EMPLOYEE IS ASSIGNED
1. EMPLOYEE NAME
2. Employee Phone
3. Last Day of Active Duty
4. Position Title
5. Forwarding Address
Series-Grade
Division or Office
PART II – TO BE COMPLETED BY THE EMPLOYEE AND ATTACHED TO THIS DOCUMENT
6. Please complete and attach the DOE Form 3250.1 (10-07) – U.S. Department of Energy Exit Interview
PART III – TO BE COMPLETED BY THE ADMINISTRATIVE OFFICER; HQ SECURITY OFFICER; AND RECORDS LIAISON OFFICER
Initial
7a. AO Action
Initial
7b. HSO Action
Initial
7c. RLO Action
Transfer or Turn in Property/Equipment
Verify ID Badge Turn in
Transfer Records
Collect Keys
Terminate Building Access
Collect RSA Token
Change Safe Combinations
Terminate LAN and Email Accounts
Contact TS Document Control Officer
Collect Purchase and/or Travel Credit Card(s)
Collect Secure Voice Telephone
Collect GETS or other Phone Calling Card(s)
Terminate Special Access
(call 6-7130)
Inform Occupational Health Unit
7a. Signature
7b. Signature
7c. Signature
ADMINISTRATIVE OFFICER
DATE
HQ SECURITY OFFICER
DATE
RECORDS LIAISON OFICER DATE
PART IV – TO BE ROUTED BY EMPLOYEE ON/OR PRIOR TO LAST DAY OF ACTIVE DUTY FOR COMPLETION BY THE ORGANIZATIONS LISTED
When clearance cannot be granted; list items to be returned and/or financial obligations in REMARKS column.
ORGANIZATION
ROOM
ITEM OR ACTION
CLEARED
NOT
SIGNATURE AND DATE OR
CLEARED
REMARKS
8. ASSISTANT
6A-211
FOR PERSONS REQUIRED TO
(6-1522)
FILE ONLY
GENERAL COUNSEL
SF-278 – Report of Financial
FOR STANDARDS
Interests and/or OGE-450 –
OF CONDUCT
Financial Disclosure Report
9.
PROPERTY OFFICE
R-006 GTN
Accountable Property
GG-087 FORS (6-5201)
Turned in or Transferred
10. DOE HQ HUMAN
GM-169 FORS
Termination of Transit
(6-1234)
Subsidy (SEET)
RESOURCES
11. PARKING OFFICE
GE-140
Parking Permits – Removal
(6-4271)
from program.
12. PASSPORT OFFICE
GE-180 FORS
Turn in Passport
( 6-3601)
Items 13 and 14 below should be the last items completed in this section; typically on the last day of active duty
13. SAFEGUARDS and
B-106 GTN
SECURITY DEBRIEFING and
1E-190 FORS
TURN IN ID BADGE
SECURITY
14. HEADQUARTERS
SEE INSTRUCTIONS
EXIT INTERVIEW and
FOR ROOM NUMBER
BENEFITS DEBRIEFING
SERVICING
PERSONNEL OFFICE
RETURN TO ADMINISTRATIVE OFFICER. ADMINISTRATIVE OFFICER SEND COPY TO PAYROLL IF FINANCIAL OBIGATIONS EXIST.
SEE INSTRUCTIONS AND PRIVACY ACT STATEMENT ON REVERSE
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