GSW
Constructors

DOCUMENTATION OF EMPLOYEE TERMINATION

Employee’s Name_______________________________________

Employee’s Soc.Sec.#_______________________Employee’s Company ID#_______________

Effective date of termination__________________

The above named employee has been terminated from employment with Joe R. Jones Construction, Inc. as of the effective date listed.

REASON FOR TERMINATION: (Check One)

( Lack of Work

( Employee Quit

( Illness or injury/unable to work

( Reduction of Force

( Fired for work related misconduct (includes insubordination or any violation of company policies, rules or regulations)

( Other: (Explain below, continue on back or separate sheet)

EXPLANATION OF REASON FOR TERMINATION:

( If employee is terminated for misconduct or illness/injury or any other reason not listed above, give details of events surrounding termination to include dates, times, witnesses, what was said and any previous warnings given. Also include dates and times of absences and tardiness if attendance is an issue.)

(Continue explanation on back or separate sheet)

EXIT INTERVIEW

An exit interview should be conducted with terminated employees if at all possible in order to ensure return of company and government property (security badges) The items listed below are a check list of items which must be returned by employees prior to receiving their final

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paycheck. If an exit interview with the terminated employee physically present is not possible, check the appropriate box below and indicate what property has been returned.

(Check the appropriate box)

( Terminated employee was not available for an exit interview, items below were/were not returned as indicated.

( An exit interview was conducted by telephone and the items below were/were not returned as indicated.

( An exit interview with the terminated employee physically present was conducted and the items below were/were not returned as indicated.

Checklist of Items to be returned (= Returned X=Not returned N/A = not applicable

( Company Tools and Equipment	( ID and Security Badges

( Company Credit Cards	( Petty Cash Advances

( Keys: vehicle,trailer, office, other	( Plans and drawings

( Cell Phone w/accessories	( Pager

( Company Vehicle	( Two way radios

( Computer w/ accessories

Other property (List below)

________________________ ______________________

________________________ ______________________

COBRA BENEFITS

(Terminating official read the following statement to terminated employee)

If you participate in the Company provided health insurance plan, you are eligible to continue that coverage under the COBRA plan at your expense. Within 30 days of termination, you will receive information explaining the details of extending this coverage.

SIGNATURES

I hereby acknowledge that I have turned in all company property in my possession

and have been advised of COBRA benefits (if applicable).

Employee________________________________________________Employee’sSignature_______________________________

(Printed Name)

JRJ Terminating _________________________________JRJ Terminating_______________________________________________

Representative (Printed Name)	Representative	(Signature)

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DOCUMENTATION OF EMPLOYEE TERMINATION

DAVID BROWN

2007-05-17

Mike Lowe

JOE R JONES CONSTRUCTION, INC