Name *

First Name

Last Name

Phone *

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Hire Date

MM

DD

YYYY

Termination Date

(if applicable)

MM

DD

YYYY

Are you a member of management? *

Yes

No

Do you have direct reports? *

Yes

No

Is your position specialized? *

Yes

No

Do you have access to confidential company information? *

Yes

No

Do you have the ability to hire/fire other employees? *

Yes

No

Do you have the ability to discipline other employees? *

Yes

No

Do you regularly schedule other employees, including overtime? *

Yes

No

Your hours of work are: *

Regular

Trregular

Are you a member of a Union? *

Yes

No

Do you have an employment contract? *

Yes

No

I don't know

Do you receive overtime pay?

Yes

No

Do you have a new job? *

Yes

No

If yes, when do/did you start the new job?

MM

DD

YYYY

Have you been disciplined? *

Yes

No

Do you have an employment contract? *

Yes

No

Reason for Termination *

With Cause

Without Cause