Fillable Employee Separation Form - Pinnacle printable pdf download

Employee Separation Form - Pinnacle

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EMPLOYEE SEPARATION FORM

Client Name: ______________________________________________________________________________

Employee Name:

SSN:

Position:

State in which Employee Worked:

First Day Worked: ___________________________

Last Day Worked:

Client Phone: ____________________________________________

Address: __________________________________________________________________________________

Completed B y ( PRINT N AME):

Date:

Client Signature:

Reason For Separation

Place a check next to the reason that most appropriately applies for the separation. Check only one.

Quit

Discharge ‐

(Must give details below)

( ) 2 ‐ No Reason Given

Name of person who discharged employee?

( ) 3 ‐ Quit (Please explain below)

What was the final incident?

Required ‐ attach written warnings and any backup

( ) 4 ‐ Mutual agreement (not protestable)

( ) 5 ‐ Failed to return from leave of absence

( ) 6 ‐ Three days unreported absence

( ) L ‐ Intoxicated on the job (Pinnacle HR Approval)

Give dates:

( )

M ‐ Left work without permission

( ) 7 ‐ Accepted other employment

( )

N ‐ Excessive absences & tardiness

( ) 8 ‐ To leave area

( )

O ‐ Fighting on company property

( ) 9 ‐ Personal

( )

P ‐ Refused to perform job duties

Q ‐ Destruction of company property

( ) B ‐ Transportation problem

( )

R ‐ Violation of company policy

( ) C ‐ Childcare problem

( )

S ‐ Insubordination

( ) D ‐ Due to medical reasons

( )

T ‐ Sleeping on job

( ) E ‐

Dissatisfied (Please explain below)

( )

( ) F ‐ Walked off job

( )

U ‐ Inability to perform job (not protestable)

( ) G ‐ Assignment completed

( )

V ‐ Violation of safety rules

( ) H ‐ Attend school

( ) X ‐

Improper conduct

( ) I – Left to work for another franchise owner

( )

Y ‐ Falsification

Lack of Work

( ) J ‐ Lack of work

( ) K ‐ Location closed

EXPLANATION (PROVIDE DETAILS FOR GROSS MISCONDUCT OR VIOLATION OF WORK RULES BY THE EMPLOYEE)

Submitting Attachments:

YES

NO (required for terminations)

Provide all supporting performance documents (Counseling Statements) for unemployment purposes.

10/2014

Employee Separation Form - Pinnacle

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