Full Name of Member: Member # or last 4 SSN: Job Title: Manager: Client Company: Client ID: Today’s Date: Separation Date: Last Day Worked: If Discharge, was Member warned prior? Yes No Eligible for rehire? Yes No Reason for Separation and Discharge: Check one and explain below. 01 – Lack of Work 03 – Voluntary Resignation No other information Reason unknown Transportation Reduce in Abandoned job Accepted another job Job Elimination Walked off job Illness Reorganization Did not return from leave Maternity End of temporary employment Personal not job related Enter Military – End of seasonal employment School Dissatisfaction with job Location closed/sold Marriage Relocate Family Obligations 04 – Discharge 08 – Retirement No other information Unauthorized removal of Company/other No other information Insubordination property Disability job related – Violation of Company rules or policies Dishonesty Disability – not job related Violation of Safety rules Absenteeism excessive/unauthorized – Violation of alcohol/drug policy Tardiness – frequent 90 – Other Failed drug test Poor job performance No activity Violation of driving policies Probationary period (90 days) Refused work Destruction of Company property- willful FMLA Expiration Disability Voluntary Resignation – Fighting on Company property Inability to work/illness/injury Transfer to ANTHROSTM Falsification of employment application Failed to provide I-9 Subscriber Failed background test 01–Lack of Work / 03–Voluntary Resignation / or 04–Discharge: Enter specific reasons/comments 08–Retirement or 90–Other: Comments Member Acknowledgement: I understand that I am being terminated from employment for the reasons set forth above. I have read and received a copy of this Separation and Discharge Statement on the date set forth below. Member Signature (if available): Date: Authorization: Required to process Manager Signature: Date: Witness (if applicable): Witness Signature (if applicable): Date: For Manager Use only: Submit this form to ANTHROSTM within 48 hours of Member separation and discharge. If category is submit form with supporting documentation. “04-DISCHARGE,” Will remuneration/compensation (other than wages for hours worked) be paid after separation and discharge? Yes* No *If Yes, submit this form with a Personnel Record Change form.
Full Name of Member: Member # or last 4 SSN: Job Title: Manager: Client Company: Client ID: Today’s Date: Separation Date: Last Day Worked: If Discharge, was Member warned prior? Yes No Eligible for rehire? Yes No Reason for Separation and Discharge: Check one and explain below. 01 – Lack of Work 03 – Voluntary Resignation No other information Reduce in Job Elimination Reorganization End of temporary employment End of seasonal employment Location closed/sold Reason unknown Abandoned job Walked off job Did not return from leave Personal – not job related School Marriage Relocate Family Obligations Transportation Accepted another job Illness Maternity Enter Military Dissatisfaction with job 04 – Discharge 08 – Retirement No other information Insubordination Violation of Company rules or policies Violation of Safety rules Violation of alcohol/drug policy Failed drug test Violation of driving policies Destruction of Company property- willful Fighting on Company property Falsification of employment application Unauthorized removal of Company/other property Dishonesty Absenteeism – excessive/unauthorized Tardiness – frequent Poor job performance Probationary period (90 days) FMLA Expiration Inability to work/illness/injury Failed to provide I-9 Failed background test No other information Disability – job related Disability – not job related 90 – Other No activity Refused work Disability – Voluntary Resignation Transfer to ANTHROSTM Subscriber 01–Lack of Work / 03–Voluntary Resignation / or 04–Discharge: Enter specific reasons/comments 08–Retirement or 90–Other: Comments Member Acknowledgement: I understand that I am being terminated from employment for the reasons set forth above. I have read and received a copy of this Separation and Discharge Statement on the date set forth below. Member Signature (if available): Date: Authorization: Required to process Manager Signature: Date: Witness (if applicable): Witness Signature (if applicable): Date: For Manager Use only: Submit this form to ANTHROSTM within 48 hours of Member separation and discharge. If category is “04-DISCHARGE,” submit form with supporting documentation. Will remuneration/compensation (other than wages for hours worked) be paid after separation and discharge? Yes* No *If Yes, submit this form with a Personnel Record Change form.