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

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*

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