EMPLOYEE'S SEPARATION CHECKLIST

Employee Name __________________________

Date of Termination ________________________

Prior to your separation from the company, the following items are to be returned to the company. Please return all the items listed below to your manager prior to your separation date.

[ ] All keys returned.

[ ] Company vehicle keys returned.

[ ] Company vehicle returned.

[ ] Company credit cards returned.

[ ] Company phone credit cards returned.

[ ] Company equipment returned (e.g., portable phones, beepers, PCs).

[ ] COBRA election forms signed and returned.

[ ] 401K election forms signed and returned.

[ ] Profit sharing election forms signed and returned.

In compliance with company policy, your files, desk and work area will be inventoried for all equipment given to you by the company.

[ ] Desk and working premises inventoried.