Employee Termination

Requestor's Name *

First

Last

The name of the person completing this form

Terminating Employee Information

Name *

First

Last

Termination Date & Time

Date

Time

If access to this user's account is necessary for continuity of business operations, provide the email address of the appropriate user(s) for ongoing access

Type of Termination

Voluntary
Involuntary
Emergency

Date to Remove Employee Access

VitalCare email address *

Personal Email

Personal Contact Number

VitalCare Equipment to be returned

Who is collecting the equipment

First

Last

VitalCare Security Access – Do they have badge access to office?

Yes
No

Property Security Access – Do they have a building FOB?

Yes
No

Subscriptions and access to terminate

…if Other

Additional Comments or Questions