Tennessee State University
EMPLOYEE EXIT FORM
Employee Name (Print): _________________________________
Date: ________________________________________
Department: ___________________________________________
T#: ________________________________________
Position Title: __________________________________________
Last Day Worked: _____________________________
Forwarding Address:
Your Contact Information:
Street:
___Same ___ New
________________________________________
City: _____________________ State: ____ Zip Code: ________
Phone Number: (____) ____ - _______
Personal E-Mail: _______________________________
You are required to visit each department listed below, and obtain the original signature of the person authorized to certify
that any outstanding obligations to the University have been met.
1.
Any outstanding financial obligations to the university have been paid. __Yes __No __ N/A
If No, list the amount of funds owed below.
Verified by:
2.
Extension: 7582 or 7638
______________________________________
Parking Services
___________________
Date
Extension: 1482
Any outstanding Educational Assistance payback provisions have been paid. ___ Yes __ No __ N/A
If No, list the amount of funds owed below.
Verified by:
4.
___________________
Date
Any parking fees/fines have been paid. Decal and Identification Badge have been returned. __Yes __No __ N/A
If No, list the amount of funds owed below.
Verified by:
3.
_____________________________________
Bursar’s Office
______________________________________
Human Resources
___________________
Date
Extension: 1237
Time and Effort Certifications are current and submitted. __Yes __No __ N/A
Verified by:
______________________________________
Grants Administration
___________________ Extension: 2186
Date
I certify that I have obtained original signatures of authorized persons.
Signed: ____________________________________________________ Date: ______________________
Funds Owed:
Bursar’s Office: $______________
Parking Services $____________
Human Resources $ ____________
If any funds are owed, you must agree to have funds deducted from your final paycheck. If there are insufficient funds in your final
paycheck to cover monies owed to TSU, you must make arrangements for payment with the Bursar’s Office. Complete the following:
I authorize Tennessee State University to withhold $____________ (sum of all amounts listed above) from my final paycheck.
Employee Signature: __________________________________________ Date: __________________
Are you leaving to work at another State Agency/Department? ___ Yes ___ No
If yes, Effective Date: __/__/____ Agency/Department ____________________________ Contact Name: ____________________
Return this form to the Office of Human Resources via fax to (615) 963-5027, via e-mail at [email protected] or in person.
Revised 11/2015 – The Office of Human Resources/Copy to Personnel File