NAME OF EMPLOYEE: ______________________________________________________________ Please print EFFECTIVE DATE OF SEPARATION: _____/_____/_____ Please check property returned (if not applicable to employee, indicate N/A) _____ Keys _____ Company Credit Card _____ Gasoline Credit Card _____ Company I.D. _____ Laptop _____ Printer _____ Other Electronic Equipment: ___________________________________________________ _____ Cell Phone _____ Pager _____ Company Documents: ________________________________________________________ _____ Uniform _____  Other: ____________________________________________________________________ Employee Signature: ______________________________________Date: ____/____/____ Supervisor Signature: ______________________________________Date: ____/____/____ Human Resources Signature: ________________________________Date: ____/____/____