» Independence – User Separation Request

Terminated Employee's Name:*

First Last

Is the terminated employee a head of a department?

Please select their email from below:*

Terminated Employee's Email:*

Enter Email Confirm Email

What date will the employee be terminated?*

Should we archive/back up their data?*

If known, what is their PCC username?

Additional Info:

Your Name:*

First Last

Your Email:*

Enter Email Confirm Email

What's the best way to contact you?

Cell Phone #:*

Office Phone #:*

How should we contact you?*

Name

This field is for validation purposes and should be left unchanged.

Independence – User Separation Request