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
□ Retirement
□ Voluntary
□ Disability
□ 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
□ Other
Remarks
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
