Attachment 8 - WAPAF3000_56b.pdf

WAPA F 3000.56b# (8-00)

U.S. DEPARTMENT OF ENERGY

WESTERN AREA POWER ADMINISTRATION

CONTRACTOR/CONSULTANT DEPARTURE NOTIFICATION FORM

GENERAL INFORMATION

1. Employee Name: 2. Organization/Mail Code:

3. Date of Departure: 4. Forwarding Address:

5. Contract Company Name:

Leaving the Western task under contract

Transferring within same Contract (specify)

Transferring to another Contract (specify)

CLEARANCE ACTION

1. SECURITY OFFICE, 2nd Floor westwing, 231C

Badge, Collected:

Yes

No

Access Card, Collected: Cleared By: Date: / /

Yes

No

2. INFORMATION SERVICES:

Disable Account By: Date: / /

Cleared By: Date: / /

Files E-mail

Deleted on: / / Deleted on: / /

Transfer to: Proxy to:

3. TELECOMMUNICATIONS:

Disable Service By: Date: / /

Cleared By: Date: / /

4. PROPERTY:

Accounted for

Missing Equipment Type:

Location

Collected:

Pager

Keys Cleared By: Date: / /

Cell Phone

CERTIFICATION

I certify all government property, credentials, issued to me have been surrendered to appropriate personnel.

Employee Signature Date

COR Signature Date