Employee Name: _______________________________

Supervisor: ___________________________________

Job Title: _____________________________________

Office: _______________________________________

Hire Date: ____________________________________

Termination Date: ______________________________

Last Date Worked: _____________________________

Reason for Termination (Please Circle Why)
Voluntary

Personal Reasons: (explain)

Took Another Position
Retirement
Relocating
Returning to School
Other _______________________

Involuntary

Position Eliminated
Attendance
Reorganization
Violation of Company Policy (explain)
Other _______________________

Explain Termination Reason _____________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________________

Need to hire Replacement Eligible for Re-Hire? YES NO

Payroll Use Only

QuickBooks __________________ Insurance ___________________

Time Clock___________________ COBRA ______________________

Field Routes Password Reset_____ Email________________________

Field Routes Deactivate_________ Non-Compete Letter___________

Vacation Payout_______________ Commission Payout_____________

Last Payroll____________________ Direct Deposit_________________

Employee Questionnaire
What is your primary reason for leaving? If multiple, please specify.
______________________________________________________________________
___________________________________________________________________________________________

Would you consider returning to work for this company in the future?
______________________________________________________________________

What did you find most satisfying about your job?
____________________________________________________________________________________________________________________________

What did you find most frustrating about your job?
_____________________________________________________________________
_____________________________________________________________________________________________________________________________

Returned:

Shirts ______________
Coats _____________
Tablet #: ___________
Study books ________
Vehicle keys ________

Fuel card #: _____________
Office Key _______________
Bank Card ______________
Passwords Updated _______
Paper work/Route ________
Vehicle checked back in and accounted for. Vehicle #: _________

Comments:
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________

Employee Signature: ____________________________________________

Date: ________________________

Employee refused to sign Employee unavailable to sign

Supervisor Signature: ___________________________________________

Date: ________________________