HTML Preview Student Employment Separation Notice page number 1.
Student Employment Separation Notice
Employee Name: _______________________ ________ Student ID #: ________ _________________
Department Name: _____________________________ Date Employment Will End: _______________
Student Position Title: ___________________________________________ ____________
Reason for Separation: Graduated Quit Fired Lack of Funds Lack of Work Other
Employers Account Number: ___ ___ - ___ ___ ___ ___ ___ - ___ ___ ___ ___ ___ ___
(Account student is being paid out of, 13 digit number)
Employers Account Number: ___ ___ - ___ ___ ___ ___ ___ - ___ ___ ___ ___ ___ ___
(Account student is being paid out of, 13 digit number)
I CERTIFY that the above worker has been separated from work and the information furnished here on
is true and correct. This report has been given to the Student Employment Office.
Department/Student Supervisor: _______________________________ __ _ ___________
(Signature) (Date)
Department/Student Supervisor Printed Name: ____________________________ _ _____ ____
(Printed Name) (Date)
Student Employment Office: _______________________________________________ __________
(Signature) (Date)
Notice to Employer:
Within 48 hours of separation you need to submit this form to the department of Human Resources. This process eliminates the chance of a
student being overpaid by your department. The Payroll Office and the Business Office will be notified of your decision to release the student
worker and on what grounds you have done such.
Student Employment Office
Lower Simmons 104
Phone: 614-8699; Email: hrintern2@leeuniversity.edu
For Office Use Only
Student Employment Office: Payroll Office:
Data Entry: _____________ Data Entry: ___________
Processed: _____________ Complete: ___________