Payroll Termination
Name A#
Department Account Number
Job Title/Rank Account Number
Last Day Worked Date Off Payroll
Reason for Termination
Lack of Work Leave of Absence from to
Left of Own Accord
Voluntary quit
Illness or injury
Withdrew from University
Transfer to another campus department
Discharged (Explain in detail under remarks and give
dates of warnings and prior violations.)
At-will employee
Violation of University Rules and Regulations
Labor Dispute
Signature of Employee Date
Requested By Date
Department Head/Account Administrator’s Signature
Concurrence Date
Appropriate Vice President (for non-student employees)
For HR Office Use
Human Resources Approval Date
Director of Human Resources (For student employees only)
Copy to Budget Office
(If a regular employee)
Date to Payroll Calculation
Print Form