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Voluntary Termination Please Check One: Involuntary Termination INDIVIDUAL INFORMATION Individual Name: Individual ID : Address: City: State: Zip Code: Phone Number: EMPLOYEE INFORMATION Employee Name: Employee ID : Address: City: State: Zip Code: Phone Number: Last Date of Employment: Employment Status: / Part Time Number of Hours Usually Worked: / Full Time Per Day Per Week Reason for Separation from Employment: Employee failed to report for work for consecutive days Employee quit with verbal notice Employee quit with written notice Employer no longer had work available for employee at time of separation (lay-off) Employee dismissed (fired) for the following reasons: SIGNATURE EMPLOYER/DESIGNATED REPRESENTATIVE SIGNATURE DATE DMH-DD: Employee Termination Form Page 1 of 1.
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