Separation Form

Complete this form for any staff not working over the summer even if they are returning as a staff member next Fall

Name of Employee * First Last
Date of Separation * / MM / DD YYYY
Position * RA OA
Community person is leaving *

i.e. Maple Square 123 or Arlington 134
1000# *
Reason for Leaving * Graduating Resigning for personal reasons Taking another position on campus Termination Leaving for the summer/returning for fall Other( please fill in reason below)
Paragraph
Your Email Address
Will this person have to move out of their room (University Housing Purposes Only) * Yes No