Employee Checkout Confirmation Form
Complete this Employee Checkout Confirmation Form to document the departure process, confirm returned items, and finalize access revocation.
Employee Full Name
*
First Name
Last Name
Department
*
Job Title/Position
*
Last Working Day
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
List of Returned Company Items (select all that apply)
*
Laptop
Mobile Phone
ID Badge
Access Card
Keys
Other
Have all system and building accesses been revoked?
*
Yes
No
Name of Manager or Supervisor Completing Checkout
*
Date of Confirmation
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Additional Comments
Final Acknowledgment Signature
*
Submit Checkout Confirmation
Submit Checkout Confirmation
Should be Empty: