Transcription of Tennessee State University EMPLOYEE EXIT FORM
1 Tennessee State University EMPLOYEE exit FORM EMPLOYEE Name (Print): _____ Date: _____ Department: _____ T#: _____ Position Title: _____ Last Day Worked: _____ Forwarding Address: ___Same ___ New Your Contact Information: Street: _____ Phone Number: (____) ____ - _____ City: _____ State : ____ Zip Code: _____ 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.
2 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: _____ _____ Extension: 7582 or 7638 Bursar s Office Date 2. 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: _____ _____ Extension: 1482 Parking Services Date 3. Any outstanding Educational Assistance payback provisions have been paid.
3 ___ Yes __ No __ N/A If No, list the amount of funds owed below. Verified by: _____ _____ Extension: 1237 Human Resources Date 4. Time and Effort Certifications are current and submitted. __Yes __No __ N/A Verified by: _____ _____ Extension: 2186 Grants Administration 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.
4 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 or in person. Revised 11/2017 The Office of Human Resources/Copy to Personnel File
