- Employee Name: _______________________
- Employee ID: _______________________
- Department: _______________________
- Position/Title: _______________________
- Last Day of Employment: _______________________
- Supervisor: _______________________
| Item | Serial/Asset Number | Returned | Condition | Notes |
|---|
| Laptop/Desktop | | □ Yes □ No □ N/A | | |
| Monitor(s) | | □ Yes □ No □ N/A | | |
| Docking Station | | □ Yes □ No □ N/A | | |
| Mouse | | □ Yes □ No □ N/A | | |
| Keyboard | | □ Yes □ No □ N/A | | |
| Headset | | □ Yes □ No □ N/A | | |
| Webcam | | □ Yes □ No □ N/A | | |
| Speakers | | □ Yes □ No □ N/A | | |
| Printer | | □ Yes □ No □ N/A | | |
| External Hard Drive | | □ Yes □ No □ N/A | | |
| USB Drives | | □ Yes □ No □ N/A | | |
| Power Adapters | | □ Yes □ No □ N/A | | |
| Cables | | □ Yes □ No □ N/A | | |
| Other: _____________ | | □ Yes □ No □ N/A | | |
| Item | Serial/Asset Number | Returned | Condition | Notes |
|---|
| Smartphone | | □ Yes □ No □ N/A | | |
| Tablet | | □ Yes □ No □ N/A | | |
| Mobile Hotspot | | □ Yes □ No □ N/A | | |
| SIM Card | | □ Yes □ No □ N/A | | |
| Phone Charger | | □ Yes □ No □ N/A | | |
| Other: _____________ | | □ Yes □ No □ N/A | | |
| Item | ID/Number | Returned | Notes |
|---|
| Building Access Card/Badge | | □ Yes □ No □ N/A | |
| Office/Desk Keys | | □ Yes □ No □ N/A | |
| File Cabinet Keys | | □ Yes □ No □ N/A | |
| Parking Pass/Card | | □ Yes □ No □ N/A | |
| Safe Combinations | | □ Yes □ No □ N/A | |
| Security Codes | | □ Yes □ No □ N/A | |
| Other: _____________ | | □ Yes □ No □ N/A | |
| Item | Account Number (Last 4) | Returned/Cancelled | Notes |
|---|
| Corporate Credit Card | | □ Yes □ No □ N/A | |
| Purchasing Card | | □ Yes □ No □ N/A | |
| Gas Card | | □ Yes □ No □ N/A | |
| Expense Reports Reconciled | | □ Yes □ No □ N/A | |
| Petty Cash Returned | | □ Yes □ No □ N/A | |
| Other: _____________ | | □ Yes □ No □ N/A | |
| Item | Returned | Notes |
|---|
| Company Manuals | □ Yes □ No □ N/A | |
| Customer/Client Files | □ Yes □ No □ N/A | |
| Project Files/Documents | □ Yes □ No □ N/A | |
| Confidential Information | □ Yes □ No □ N/A | |
| Company Intellectual Property | □ Yes □ No □ N/A | |
| Business Cards | □ Yes □ No □ N/A | |
| Other: _____________ | □ Yes □ No □ N/A | |
| Item | Quantity | Returned | Notes |
|---|
| Uniforms | | □ Yes □ No □ N/A | |
| Safety Equipment | | □ Yes □ No □ N/A | |
| Tools | | □ Yes □ No □ N/A | |
| Company Vehicle | | □ Yes □ No □ N/A | |
| Other: _____________ | | □ Yes □ No □ N/A | |
| System | Access Removed | Date | Completed By |
|---|
| Email Account | □ Yes □ No □ N/A | | |
| Network Access | □ Yes □ No □ N/A | | |
| VPN Access | □ Yes □ No □ N/A | | |
| CRM System | □ Yes □ No □ N/A | | |
| Financial Systems | □ Yes □ No □ N/A | | |
| Project Management Tools | □ Yes □ No □ N/A | | |
| Client Portals | □ Yes □ No □ N/A | | |
| Website Admin Access | □ Yes □ No □ N/A | | |
| Social Media Accounts | □ Yes □ No □ N/A | | |
| Cloud Storage | □ Yes □ No □ N/A | | |
| Other: _____________ | □ Yes □ No □ N/A | | |
Please list any company property that is missing, damaged, or not returned:
| Item | Description of Issue | Replacement Cost | Resolution |
|---|
| | | |
| | | |
| | | |
I certify that I have returned all company property in my possession as indicated above. I understand that failure to return company property may result in deductions from my final paycheck where permitted by law, and/or legal action.
I also acknowledge that I remain bound by any confidentiality, non-disclosure, non-compete, and/or non-solicitation agreements I have signed during my employment.
Employee Signature: __________________________ Date: __________
I verify that the above-listed company property has been returned as indicated.
Name: __________________________ Title: __________________________
Signature: __________________________ Date: __________
| Department | Name | Signature | Date |
|---|
| Direct Supervisor | | | |
| IT Department | | | |
| HR Department | | | |
| Finance Department | | | |
| Facilities | | | |
Note: Please provide a copy of this completed form to the employee and retain the original in the employee’s personnel file.