Title Page
EMPLOYEE INFO
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Name (Type here or use Sign option to write):
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Today's Date:
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ID# (Type here or use Sign option to write):
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Category:
REASONS FOR SEPARATION (More than one can be checked).
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- Layoff
- Absenteeism (Termination)
- Insubordination (Termination)
- Tardiness (Termination)
- Resignation (Termination)
- Non-Compliance of Company Policy (Termination)
- Unsatisfactory Work Performance (Termination)
- Violation of Safety Rules (Termination)
NOT FOR REHIRE
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Comment / State Reason (Type here or use sign option to write):
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Supervisor Name (Type here or use Sign option to write):
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Supervisor Title:
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Supervisor Phone (Type here or use Sign option to write):
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Project Title:
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Supervisor signature:
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Employee Signature:
