Employment Separation Form

Please complete and submit this form for each separated employee.

Employer Name:
Separated Employee's Full Name:
Last Four of Employee's Social Security Number:
Date of Separation/Last Day Worked:
Reason for Separation:
Eligible for Rehire (Yes or No):
Supervisor Name:
Name and Title of Person Submitting this Update:
Comments: Please note: was the member laid off?* *did the member quit?* *was the member terminated?*