Employee Information

First Name*
Last Name*
Employee ID Number*

(Example: 4XA001234 - can be obtained from wage review spreadsheets)
Position*
Do you have an LOA Date or Term Date?*
- LOA Date
- Term Date
LOA Date
Term Date
Clinic or Dept*
Personal Email Address*

(Enter NA, if you do not have an email address)
Preferred Phone Number
Address*
Street Address City State ZIP Code
Date communicated*
Remote Employee?*
(Not in or near Manitowoc)
IT items to be collected*