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If terminated list the termination date Date of final pay check Employer Signature Date Customer Signature Additional verification will be required if employer does not sign form. Return form to employee or to DWS. If returning to DWS mail email or fax to Salt Lake City Area 801-526-9500 Imaging Operations Toll free 1-877-313-4717 P. Salary /Monthly Yearly Number of hours worked each week Check scheduled work days Mon Tues Wed Thurs Fri Sat Sun Enter work schedule ex 9 a*m*to 6 p*m* From a*m* / ...

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