Employer (Client Name) Client ID No.

Employee Name:

Date of Separation: Eligible for Rehire: Yes

Reason for Separation: (Check one & attach documentation) Lack of Work:

Quit:

Dissatisfaction with:

Other:

Workforce reduction

Job eliminated

Reorganization

Temporary job ended

End of seasonal employment

Discharge:

Insubordination

Violation of company rules or policies

Violation of safety rules

Reported under in uence of alcohol/drugs

Willful destruction of company property

Careless destruction of company property

Fighting on company property

Leaving workstation

Falsi cation on employment application

Falsi ed company records

Monetary theft

Dishonesty – other

Unauthorized removal of company property

Absenteeism - unreported

Excessive absences/tardiness

Quality of work

Quantity of work

Performance - Poor

Reason unknown

Walked off job

Personal/Family

School

Marriage

Relocation

Transportation

Accepted another job

Going into own business

Illness

Maternity

Military

No call/no show

Work hours

Salary

Working conditions

Performance review

Supervisor

Company policy

Death

Other

Remuneration Paid After Separation:

Vacation pay

Severance pay

Other

No

Signature/Title of Employer Representative Date

By signing below, employee acknowledges only receipt of this form. This is in no way an admission to any wrongdoing or an agreement to any other details recorded on this form.

Employee Signature Date

Remarks

Name/Title of Person Who Discharged Employee:

SSN:

NOTICE OF EMPLOYMENT SEPARATION

Virginia Mathes

required of this position.

HRHIC Industries, Inc. DBA Softwash Systems 80483

Ted Michaelis

09/18/2023

Jennie has not demonstrated the organizational skills and attention to detail 09/18/2023

Ted Michaelis 09/18/2023

***-**-****

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