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2001 Fisher & Phillips LLP
EMPLOYEE SEPARATION CHECKLIST
NAME OF EMPLOYEE: ________________________________________________________
EFFECTIVE DATE OF SEPARATION: ___________________________________________
In connection with the separation of your employment, you have the following obligations: (Please
initial all that apply)
Return all Company materials, documents, data, etc., whether in paper or electronic form
("Materials")
Return all Company equipment and property ("Equipment"), including, but not limited to:
Keys to Company property
Parking/building access card
Toll Road transponder
Computer equipment:
Computer, Model ________________________
Laptop, Model ________________________
Printer, Model ________________________
Cell phone/pager
Company credit cards
Other (specify) ____________________________________________________________
Repay any outstanding advances owed to the Company. Expense advances, vacation
advances and debts owed by the employee to the Company that are subject to repayment
through payroll deductions will be deducted from the final check to the extent permitted by
law.
Comply with the Company's [trade secret and confidentiality agreement],* including your
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2001 Fisher & Phillips LLP
continuing obligation to maintain the confidentiality of Company proprietary information.
Your access to the Company's computer ends on: __________________
Password: ______________
Your access to the Company's voice mail ends on: __________________
Your access to the Company's property ends on: __________________
Your ability to act for the Company ends on: __________________
Your health/dental/vision benefits will terminate on: __________________
You were informed about your Cal Cobra Health
Insurance rights on: __________________
You received a copy of the State of California
Unemployment/Disability booklet on:
__________________
Your final pay (including vacation pay) in the
amount of: $_________________
Received on: ______________
Other checks received __________________
$_________________
Received on: ______________
Please sign below indicating that you agree and accept the information above.
________________ ___________________________________
Date
Employee Signature
___________________________________
Print Name
________________ ___________________________________
Date
Employer Signature
___________________________________
Print Name
__________________________
*Insert name of agreement
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