Phone: (541) 383‐7221
FAX No: (541) 317‐3066
NOTICE OF TERMINATION OF EMPLOYMENT (TALX Form)
Instructions: Please complete this form to the best of your knowledge and return it to Payroll. Please be sure to sign and date the
form in the space indicated. This completed form is necessary to enable Payroll to complete their employment records and to
process your final paycheck. Your promptness in returning this form will be greatly appreciated.
Name of Employee _______________________________________________________________
Last, First, Initial (Other Names Used)
Current Address: ________________________________________________________________
City, State, Zip Code ______________________________________________________________
If you are relocating, please provide forwarding address.
This address will be used for W-2 tax information:
COCC ID #: ________________________ Last Working Day: __________________________
Reason for Termination:
____ Laid off/Lack of Work ____Resigned ____Discharged ____Resigned in Lieu of Discharge ___Other
Please Provide Explanation: _______________________________________________________
(If more room is needed for explanation, please use a separate sheet of paper)
Check the applicable box below and carefully read the vacation requirements:
_____ Classified Employee - I request that all unused vacation hours be refunded to me at the time of termination.
I understand I need to give 2 weeks’ notice to receive a vacation payout.
_____ Administrative Employee - With my supervisor's approval, please refund all unused vacation hours.
I hereby certify that the above information and reason for termination are correct:
Employee's Signature: __________________________________________ Date: _____________
TO BE FILLED OUT BY PAYROLL DEPARTMENT:
Date Hired: _____________ Date Terminated:_____________
Rate of Pay: $_____________ per _____________Vacation Pay _____________ $_____________
Number of Days Amount
* * * * * * * * * * * * * * * * * * *
_____________ _______________________________________ Eligible for Rehire: ( ) Yes ( ) No
Date Director of Human Resources
Original: Payroll Copy: Human Resources
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