Employer Services Company Contact Information

Separation Input Form

2024 State Street
Granite City, Illinois 62040

Phone: (314) 727-8015 or (618) 451-9612
Fax: (314) 727-4051 or (618) 451-9619
Email: jjb@empsvcs.com

Today's Date: 7/29/2010
Please fill in the following information:

Company Name:
Employee Name:
SSN:
State worked:
Title or Position:
First Day:
Last Day:
Term Day:
Rate of Pay:
Pay Period:
Category of Termination:
Reasons Quit (if applicable):
	Left of own accord - No reason given.
	To accept other employment.
	Personal / Domestic reasons (Explain below in remarks)
	Illness or injury (Explain below in remarks).
	Pregnancy.
	1 to 3 Consecutive days unreported absence. Dates ?
	To leave area. Change of residence
	To attend school.
	Other (Explain below in remarks).
Reasons Discharged: (if applicable):
	Insubordination. (Please explain below)
	Improper conduct (Please explain below)
	Drinking on duty (When, Where?)
	Reporting under the influence of alcohol/drugs
	Violation company rule/policy (Specify)
	Falsified Records
	Dishonesty - Signed statement (Specify)
	Unreported absence. (Dates ?)
	Excessive tardiness/absence (Dates ?)
	1 to 3 Consecutive Days Unreported Absence (Dates ?)
	Failed Drug/Alcohol test. (Explain type of drug below:)
	Other (Explain below in remarks)
Job Refusal:
Date Job Refused:
Rate of Pay:
Type of work offered:
Lack of work:
Date:	Return Date (if not indefinite):
Leave of absence:
From:	To:
Remuneration after Separation:
Vacation Pay:
From	To
Severance Pay:
From	To
Workers Comp:
From	To
Pension Amount:
Financed by Employer:	Wholly > 50% < 50%
Labor Dispute:
Date Commenced:	Withholding services? Y N
Striking Union:	Member of the Union? Y N
Picket lines up? Y N	Work available now? Y N


Remarks: (Please fax or mail any additional documentation: counseling forms, resignation forms, etc.)

E-mail a copy of this form to:
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