___ Keys        ___ Jacket     ___ Ties           ___ Pants
    ___ Beeper     ___ Shirt       ___ Rain Gear   ___ Radio   ___ other

Describe Details of Exit Interview:




THE FOLLOWING MATERIALS WERE GIVEN OR MAILED TO FORMER EMPLOYEE:

   ____ COBRA Letter & Election form

   ____ HIPP Letter

   ____ State Disability Insurance Provisions (EDD Pamphlet)

   ____ California's Programs for the Unemployed

THE FOLLOWING WAS COMPLETED:

   ____ Change in Status Form

   ____ Delete person from health, dental and life insurance policies



Signature:_____________________________________   Date:___________