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Employee Information
First Name
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Last Name
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Employee ID Number
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(Example: 4XA001234 - can be obtained from wage review spreadsheets)
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Do you have an LOA Date or Term Date?
*
LOA Date
Term Date
LOA Date
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Term Date
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1921
1920
Clinic or Dept
*
Personal Email Address
*
(Enter NA, if you do not have an email address)
Preferred Phone Number
Address
*
Street Address
City
State
Alabama
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Armed Forces Americas
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ZIP Code
Date communicated
*
Month
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Year
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2021
2020
2019
2018
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2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
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1974
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1972
1971
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1961
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1953
1952
1951
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1948
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1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
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1925
1924
1923
1922
1921
1920
Remote Employee?
*
Yes
No
(Not in or near Manitowoc)
IT items to be collected
*