Separation Notice

SEPARATION NOTICE Effective Date Name Department Shift Position Supervisor Hire Date Last Day Worked TYPE OF SEPARATION Resignation Mutual Agreement Leave of Absence Other Discharge Layoff Retirement EVALUATION ITEM Quality of Work Productivity Attitude Conduct Attendance Would you re-employ? Yes Signed: Approved: No With some reservation Date Date Outstanding Satisfactory Unsatisfactory REASON Personal Better Position Absenteeism/Lateness Other Remarks: Poor Productivity Company Rules Violation Lack of Work American LegalNet, Inc. www.FormsWorkFlow.com 2001 © American LegalNet, Inc.