Employment Termination Security Statement
Please complete this form to document the return of company property and acknowledgment of security obligations upon termination of employment.
Employee Full Name
*
First Name
Last Name
Employee ID (Last 4 digits only)
*
Department
*
Position/Title
*
Last Working Day
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Reason for Termination
*
Please Select
Resignation
Layoff/Redundancy
Termination for Cause
Retirement
Other
Company Property Returned (check all that apply)
*
Laptop/Computer
Mobile Phone
ID Badge/Access Card
Keys
Documents/Files
Other Equipment
Other
Access Removed From (check all that apply)
*
Email Account
Company Network
HR/Payroll System
Building Access
Other Systems
Other
Supervisor/Manager Name
*
Additional Comments or Notes
Employee Signature
*
Date Signed
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Submit
Should be Empty: