SlideShare a Scribd company logo
15869
CORRECTIVE ACTION REPORT
NAME: Jane Doe Employee ID: 004755 JOB TITLE: Cashier
EMPLOYMENT DATE: November 4, 2016 STORE #: 999 DATE: June 4, 2019
PREVIOUS WARNINGS (dates and nature of offence):
CAR # 15818 October 12, 2018 Verbal Warning – Late for scheduled shift
CAR # 15827 December 23, 2018 Written Warning – Late for scheduled shift
CAR # 15839 February 17, 2019 1-day suspension – Late for scheduled shift
CURRENT INFRACTION:
Late for scheduled shift – 8 to 4:30 on Sunday June 2, 2019.
SUMMARY OF CIRCUMSTANCES SURROUNDING THE INFRACTION:
Jane was an hour late for her scheduled shift on Sunday June 2nd. Her shift was to start at 8am
and she did not arrive until 9am. When questioned, Jane stated that she slept in.
ADDITIONAL COMMENTS:
It is Jane’s responsibility to show up for scheduled shifts on time. Any future incidents of similar
nature may result in more severe corrective action, up to and including termination.
ACTION TAKEN: WARNING ________ SUSPENSION 3-days TERMINATION: _____
(check one)
_______________________ _________________________
EMPLOYEE’S SIGNATURE (acknowledging receipt) MANAGER’S SIGNATURE
*note – manager should sign last
_______________________ _________________________
SHOP STEWARD/WITNESS(Signature) MANAGER (print name)
_______________________
SHOP STEWARD/WITNESS (print name)
Distribution of Copies:
1. Original - Retain at Store [personnel file]
2. Copy - Employee
3. Copy - [shop steward]

More Related Content

Recently uploaded

一比一原版(liverpool毕业证书)利物浦大学毕业证如何办理
一比一原版(liverpool毕业证书)利物浦大学毕业证如何办理一比一原版(liverpool毕业证书)利物浦大学毕业证如何办理
一比一原版(liverpool毕业证书)利物浦大学毕业证如何办理
aypxuyw
 
一比一原版英国伦敦商学院毕业证(lbs毕业证书)如何办理
一比一原版英国伦敦商学院毕业证(lbs毕业证书)如何办理一比一原版英国伦敦商学院毕业证(lbs毕业证书)如何办理
一比一原版英国伦敦商学院毕业证(lbs毕业证书)如何办理
gedsuu
 
一比一原版英国伦敦大学亚非学院毕业证(soas毕业证书)如何办理
一比一原版英国伦敦大学亚非学院毕业证(soas毕业证书)如何办理一比一原版英国伦敦大学亚非学院毕业证(soas毕业证书)如何办理
一比一原版英国伦敦大学亚非学院毕业证(soas毕业证书)如何办理
duxss
 
一比一原版(uwgb毕业证书)美国威斯康星大学绿湾分校毕业证如何办理
一比一原版(uwgb毕业证书)美国威斯康星大学绿湾分校毕业证如何办理一比一原版(uwgb毕业证书)美国威斯康星大学绿湾分校毕业证如何办理
一比一原版(uwgb毕业证书)美国威斯康星大学绿湾分校毕业证如何办理
pdeehy
 
快速办理(SCU毕业证书)澳洲南十字星大学毕业证文凭证书一模一样
快速办理(SCU毕业证书)澳洲南十字星大学毕业证文凭证书一模一样快速办理(SCU毕业证书)澳洲南十字星大学毕业证文凭证书一模一样
快速办理(SCU毕业证书)澳洲南十字星大学毕业证文凭证书一模一样
15e6o6u
 
V.-SENTHIL-BALAJI-SLP-C-8939-8940-2023-SC-Judgment-07-August-2023.pdf
V.-SENTHIL-BALAJI-SLP-C-8939-8940-2023-SC-Judgment-07-August-2023.pdfV.-SENTHIL-BALAJI-SLP-C-8939-8940-2023-SC-Judgment-07-August-2023.pdf
V.-SENTHIL-BALAJI-SLP-C-8939-8940-2023-SC-Judgment-07-August-2023.pdf
bhavenpr
 
一比一原版伯恩茅斯大学毕业证(bu毕业证)如何办理
一比一原版伯恩茅斯大学毕业证(bu毕业证)如何办理一比一原版伯恩茅斯大学毕业证(bu毕业证)如何办理
一比一原版伯恩茅斯大学毕业证(bu毕业证)如何办理
ymefneb
 
一比一原版牛津布鲁克斯大学毕业证(牛布毕业证)如何办理
一比一原版牛津布鲁克斯大学毕业证(牛布毕业证)如何办理一比一原版牛津布鲁克斯大学毕业证(牛布毕业证)如何办理
一比一原版牛津布鲁克斯大学毕业证(牛布毕业证)如何办理
meboh
 
一比一原版多伦多都会大学毕业证(TMU毕业证书)学历如何办理
一比一原版多伦多都会大学毕业证(TMU毕业证书)学历如何办理一比一原版多伦多都会大学毕业证(TMU毕业证书)学历如何办理
一比一原版多伦多都会大学毕业证(TMU毕业证书)学历如何办理
woywevt
 
Sangyun Lee, 'Why Korea's Merger Control Occasionally Fails: A Public Choice ...
Sangyun Lee, 'Why Korea's Merger Control Occasionally Fails: A Public Choice ...Sangyun Lee, 'Why Korea's Merger Control Occasionally Fails: A Public Choice ...
Sangyun Lee, 'Why Korea's Merger Control Occasionally Fails: A Public Choice ...
Sangyun Lee
 
一比一原版新加坡南洋理工大学毕业证(本硕)ntu学位证书如何办理
一比一原版新加坡南洋理工大学毕业证(本硕)ntu学位证书如何办理一比一原版新加坡南洋理工大学毕业证(本硕)ntu学位证书如何办理
一比一原版新加坡南洋理工大学毕业证(本硕)ntu学位证书如何办理
hedonxu
 
一比一原版林肯大学毕业证(lincoln毕业证)如何办理
一比一原版林肯大学毕业证(lincoln毕业证)如何办理一比一原版林肯大学毕业证(lincoln毕业证)如何办理
一比一原版林肯大学毕业证(lincoln毕业证)如何办理
fexbqa
 
17-03 2022 -full agreement full version .pdf
17-03 2022 -full agreement full version .pdf17-03 2022 -full agreement full version .pdf
17-03 2022 -full agreement full version .pdf
ssuser0dfed9
 
在线办理(UNE毕业证书)新英格兰大学毕业证成绩单一模一样
在线办理(UNE毕业证书)新英格兰大学毕业证成绩单一模一样在线办理(UNE毕业证书)新英格兰大学毕业证成绩单一模一样
在线办理(UNE毕业证书)新英格兰大学毕业证成绩单一模一样
15e6o6u
 
一比一原版朴次茅斯大学毕业证(uop毕业证)如何办理
一比一原版朴次茅斯大学毕业证(uop毕业证)如何办理一比一原版朴次茅斯大学毕业证(uop毕业证)如何办理
一比一原版朴次茅斯大学毕业证(uop毕业证)如何办理
onduyv
 
It's the Law: Recent Court and Administrative Decisions of Interest
It's the Law: Recent Court and Administrative Decisions of InterestIt's the Law: Recent Court and Administrative Decisions of Interest
It's the Law: Recent Court and Administrative Decisions of Interest
Parsons Behle & Latimer
 
Corporate Governance : Scope and Legal Framework
Corporate Governance : Scope and Legal FrameworkCorporate Governance : Scope and Legal Framework
Corporate Governance : Scope and Legal Framework
devaki57
 
一比一原版(ua毕业证书)加拿大阿尔伯塔大学毕业证如何办理
一比一原版(ua毕业证书)加拿大阿尔伯塔大学毕业证如何办理一比一原版(ua毕业证书)加拿大阿尔伯塔大学毕业证如何办理
一比一原版(ua毕业证书)加拿大阿尔伯塔大学毕业证如何办理
ubype
 
THE CONCEPT OF RIGHT TO DEFAULT BAIL.pptx
THE CONCEPT OF RIGHT TO DEFAULT BAIL.pptxTHE CONCEPT OF RIGHT TO DEFAULT BAIL.pptx
THE CONCEPT OF RIGHT TO DEFAULT BAIL.pptx
Namrata Chakraborty
 
PPT-Money Laundering - lecture 5.pptx ll
PPT-Money Laundering - lecture 5.pptx llPPT-Money Laundering - lecture 5.pptx ll
PPT-Money Laundering - lecture 5.pptx ll
MohammadZubair874462
 

Recently uploaded (20)

一比一原版(liverpool毕业证书)利物浦大学毕业证如何办理
一比一原版(liverpool毕业证书)利物浦大学毕业证如何办理一比一原版(liverpool毕业证书)利物浦大学毕业证如何办理
一比一原版(liverpool毕业证书)利物浦大学毕业证如何办理
 
一比一原版英国伦敦商学院毕业证(lbs毕业证书)如何办理
一比一原版英国伦敦商学院毕业证(lbs毕业证书)如何办理一比一原版英国伦敦商学院毕业证(lbs毕业证书)如何办理
一比一原版英国伦敦商学院毕业证(lbs毕业证书)如何办理
 
一比一原版英国伦敦大学亚非学院毕业证(soas毕业证书)如何办理
一比一原版英国伦敦大学亚非学院毕业证(soas毕业证书)如何办理一比一原版英国伦敦大学亚非学院毕业证(soas毕业证书)如何办理
一比一原版英国伦敦大学亚非学院毕业证(soas毕业证书)如何办理
 
一比一原版(uwgb毕业证书)美国威斯康星大学绿湾分校毕业证如何办理
一比一原版(uwgb毕业证书)美国威斯康星大学绿湾分校毕业证如何办理一比一原版(uwgb毕业证书)美国威斯康星大学绿湾分校毕业证如何办理
一比一原版(uwgb毕业证书)美国威斯康星大学绿湾分校毕业证如何办理
 
快速办理(SCU毕业证书)澳洲南十字星大学毕业证文凭证书一模一样
快速办理(SCU毕业证书)澳洲南十字星大学毕业证文凭证书一模一样快速办理(SCU毕业证书)澳洲南十字星大学毕业证文凭证书一模一样
快速办理(SCU毕业证书)澳洲南十字星大学毕业证文凭证书一模一样
 
V.-SENTHIL-BALAJI-SLP-C-8939-8940-2023-SC-Judgment-07-August-2023.pdf
V.-SENTHIL-BALAJI-SLP-C-8939-8940-2023-SC-Judgment-07-August-2023.pdfV.-SENTHIL-BALAJI-SLP-C-8939-8940-2023-SC-Judgment-07-August-2023.pdf
V.-SENTHIL-BALAJI-SLP-C-8939-8940-2023-SC-Judgment-07-August-2023.pdf
 
一比一原版伯恩茅斯大学毕业证(bu毕业证)如何办理
一比一原版伯恩茅斯大学毕业证(bu毕业证)如何办理一比一原版伯恩茅斯大学毕业证(bu毕业证)如何办理
一比一原版伯恩茅斯大学毕业证(bu毕业证)如何办理
 
一比一原版牛津布鲁克斯大学毕业证(牛布毕业证)如何办理
一比一原版牛津布鲁克斯大学毕业证(牛布毕业证)如何办理一比一原版牛津布鲁克斯大学毕业证(牛布毕业证)如何办理
一比一原版牛津布鲁克斯大学毕业证(牛布毕业证)如何办理
 
一比一原版多伦多都会大学毕业证(TMU毕业证书)学历如何办理
一比一原版多伦多都会大学毕业证(TMU毕业证书)学历如何办理一比一原版多伦多都会大学毕业证(TMU毕业证书)学历如何办理
一比一原版多伦多都会大学毕业证(TMU毕业证书)学历如何办理
 
Sangyun Lee, 'Why Korea's Merger Control Occasionally Fails: A Public Choice ...
Sangyun Lee, 'Why Korea's Merger Control Occasionally Fails: A Public Choice ...Sangyun Lee, 'Why Korea's Merger Control Occasionally Fails: A Public Choice ...
Sangyun Lee, 'Why Korea's Merger Control Occasionally Fails: A Public Choice ...
 
一比一原版新加坡南洋理工大学毕业证(本硕)ntu学位证书如何办理
一比一原版新加坡南洋理工大学毕业证(本硕)ntu学位证书如何办理一比一原版新加坡南洋理工大学毕业证(本硕)ntu学位证书如何办理
一比一原版新加坡南洋理工大学毕业证(本硕)ntu学位证书如何办理
 
一比一原版林肯大学毕业证(lincoln毕业证)如何办理
一比一原版林肯大学毕业证(lincoln毕业证)如何办理一比一原版林肯大学毕业证(lincoln毕业证)如何办理
一比一原版林肯大学毕业证(lincoln毕业证)如何办理
 
17-03 2022 -full agreement full version .pdf
17-03 2022 -full agreement full version .pdf17-03 2022 -full agreement full version .pdf
17-03 2022 -full agreement full version .pdf
 
在线办理(UNE毕业证书)新英格兰大学毕业证成绩单一模一样
在线办理(UNE毕业证书)新英格兰大学毕业证成绩单一模一样在线办理(UNE毕业证书)新英格兰大学毕业证成绩单一模一样
在线办理(UNE毕业证书)新英格兰大学毕业证成绩单一模一样
 
一比一原版朴次茅斯大学毕业证(uop毕业证)如何办理
一比一原版朴次茅斯大学毕业证(uop毕业证)如何办理一比一原版朴次茅斯大学毕业证(uop毕业证)如何办理
一比一原版朴次茅斯大学毕业证(uop毕业证)如何办理
 
It's the Law: Recent Court and Administrative Decisions of Interest
It's the Law: Recent Court and Administrative Decisions of InterestIt's the Law: Recent Court and Administrative Decisions of Interest
It's the Law: Recent Court and Administrative Decisions of Interest
 
Corporate Governance : Scope and Legal Framework
Corporate Governance : Scope and Legal FrameworkCorporate Governance : Scope and Legal Framework
Corporate Governance : Scope and Legal Framework
 
一比一原版(ua毕业证书)加拿大阿尔伯塔大学毕业证如何办理
一比一原版(ua毕业证书)加拿大阿尔伯塔大学毕业证如何办理一比一原版(ua毕业证书)加拿大阿尔伯塔大学毕业证如何办理
一比一原版(ua毕业证书)加拿大阿尔伯塔大学毕业证如何办理
 
THE CONCEPT OF RIGHT TO DEFAULT BAIL.pptx
THE CONCEPT OF RIGHT TO DEFAULT BAIL.pptxTHE CONCEPT OF RIGHT TO DEFAULT BAIL.pptx
THE CONCEPT OF RIGHT TO DEFAULT BAIL.pptx
 
PPT-Money Laundering - lecture 5.pptx ll
PPT-Money Laundering - lecture 5.pptx llPPT-Money Laundering - lecture 5.pptx ll
PPT-Money Laundering - lecture 5.pptx ll
 

Featured

2024 State of Marketing Report – by Hubspot
2024 State of Marketing Report – by Hubspot2024 State of Marketing Report – by Hubspot
2024 State of Marketing Report – by Hubspot
Marius Sescu
 
Everything You Need To Know About ChatGPT
Everything You Need To Know About ChatGPTEverything You Need To Know About ChatGPT
Everything You Need To Know About ChatGPT
Expeed Software
 
Product Design Trends in 2024 | Teenage Engineerings
Product Design Trends in 2024 | Teenage EngineeringsProduct Design Trends in 2024 | Teenage Engineerings
Product Design Trends in 2024 | Teenage Engineerings
Pixeldarts
 
How Race, Age and Gender Shape Attitudes Towards Mental Health
How Race, Age and Gender Shape Attitudes Towards Mental HealthHow Race, Age and Gender Shape Attitudes Towards Mental Health
How Race, Age and Gender Shape Attitudes Towards Mental Health
ThinkNow
 
AI Trends in Creative Operations 2024 by Artwork Flow.pdf
AI Trends in Creative Operations 2024 by Artwork Flow.pdfAI Trends in Creative Operations 2024 by Artwork Flow.pdf
AI Trends in Creative Operations 2024 by Artwork Flow.pdf
marketingartwork
 
Skeleton Culture Code
Skeleton Culture CodeSkeleton Culture Code
Skeleton Culture Code
Skeleton Technologies
 
PEPSICO Presentation to CAGNY Conference Feb 2024
PEPSICO Presentation to CAGNY Conference Feb 2024PEPSICO Presentation to CAGNY Conference Feb 2024
PEPSICO Presentation to CAGNY Conference Feb 2024
Neil Kimberley
 
Content Methodology: A Best Practices Report (Webinar)
Content Methodology: A Best Practices Report (Webinar)Content Methodology: A Best Practices Report (Webinar)
Content Methodology: A Best Practices Report (Webinar)
contently
 
How to Prepare For a Successful Job Search for 2024
How to Prepare For a Successful Job Search for 2024How to Prepare For a Successful Job Search for 2024
How to Prepare For a Successful Job Search for 2024
Albert Qian
 
Social Media Marketing Trends 2024 // The Global Indie Insights
Social Media Marketing Trends 2024 // The Global Indie InsightsSocial Media Marketing Trends 2024 // The Global Indie Insights
Social Media Marketing Trends 2024 // The Global Indie Insights
Kurio // The Social Media Age(ncy)
 
Trends In Paid Search: Navigating The Digital Landscape In 2024
Trends In Paid Search: Navigating The Digital Landscape In 2024Trends In Paid Search: Navigating The Digital Landscape In 2024
Trends In Paid Search: Navigating The Digital Landscape In 2024
Search Engine Journal
 
5 Public speaking tips from TED - Visualized summary
5 Public speaking tips from TED - Visualized summary5 Public speaking tips from TED - Visualized summary
5 Public speaking tips from TED - Visualized summary
SpeakerHub
 
ChatGPT and the Future of Work - Clark Boyd
ChatGPT and the Future of Work - Clark Boyd ChatGPT and the Future of Work - Clark Boyd
ChatGPT and the Future of Work - Clark Boyd
Clark Boyd
 
Getting into the tech field. what next
Getting into the tech field. what next Getting into the tech field. what next
Getting into the tech field. what next
Tessa Mero
 
Google's Just Not That Into You: Understanding Core Updates & Search Intent
Google's Just Not That Into You: Understanding Core Updates & Search IntentGoogle's Just Not That Into You: Understanding Core Updates & Search Intent
Google's Just Not That Into You: Understanding Core Updates & Search Intent
Lily Ray
 
How to have difficult conversations
How to have difficult conversations How to have difficult conversations
How to have difficult conversations
Rajiv Jayarajah, MAppComm, ACC
 
Introduction to Data Science
Introduction to Data ScienceIntroduction to Data Science
Introduction to Data Science
Christy Abraham Joy
 
Time Management & Productivity - Best Practices
Time Management & Productivity -  Best PracticesTime Management & Productivity -  Best Practices
Time Management & Productivity - Best Practices
Vit Horky
 
The six step guide to practical project management
The six step guide to practical project managementThe six step guide to practical project management
The six step guide to practical project management
MindGenius
 
Beginners Guide to TikTok for Search - Rachel Pearson - We are Tilt __ Bright...
Beginners Guide to TikTok for Search - Rachel Pearson - We are Tilt __ Bright...Beginners Guide to TikTok for Search - Rachel Pearson - We are Tilt __ Bright...
Beginners Guide to TikTok for Search - Rachel Pearson - We are Tilt __ Bright...
RachelPearson36
 

Featured (20)

2024 State of Marketing Report – by Hubspot
2024 State of Marketing Report – by Hubspot2024 State of Marketing Report – by Hubspot
2024 State of Marketing Report – by Hubspot
 
Everything You Need To Know About ChatGPT
Everything You Need To Know About ChatGPTEverything You Need To Know About ChatGPT
Everything You Need To Know About ChatGPT
 
Product Design Trends in 2024 | Teenage Engineerings
Product Design Trends in 2024 | Teenage EngineeringsProduct Design Trends in 2024 | Teenage Engineerings
Product Design Trends in 2024 | Teenage Engineerings
 
How Race, Age and Gender Shape Attitudes Towards Mental Health
How Race, Age and Gender Shape Attitudes Towards Mental HealthHow Race, Age and Gender Shape Attitudes Towards Mental Health
How Race, Age and Gender Shape Attitudes Towards Mental Health
 
AI Trends in Creative Operations 2024 by Artwork Flow.pdf
AI Trends in Creative Operations 2024 by Artwork Flow.pdfAI Trends in Creative Operations 2024 by Artwork Flow.pdf
AI Trends in Creative Operations 2024 by Artwork Flow.pdf
 
Skeleton Culture Code
Skeleton Culture CodeSkeleton Culture Code
Skeleton Culture Code
 
PEPSICO Presentation to CAGNY Conference Feb 2024
PEPSICO Presentation to CAGNY Conference Feb 2024PEPSICO Presentation to CAGNY Conference Feb 2024
PEPSICO Presentation to CAGNY Conference Feb 2024
 
Content Methodology: A Best Practices Report (Webinar)
Content Methodology: A Best Practices Report (Webinar)Content Methodology: A Best Practices Report (Webinar)
Content Methodology: A Best Practices Report (Webinar)
 
How to Prepare For a Successful Job Search for 2024
How to Prepare For a Successful Job Search for 2024How to Prepare For a Successful Job Search for 2024
How to Prepare For a Successful Job Search for 2024
 
Social Media Marketing Trends 2024 // The Global Indie Insights
Social Media Marketing Trends 2024 // The Global Indie InsightsSocial Media Marketing Trends 2024 // The Global Indie Insights
Social Media Marketing Trends 2024 // The Global Indie Insights
 
Trends In Paid Search: Navigating The Digital Landscape In 2024
Trends In Paid Search: Navigating The Digital Landscape In 2024Trends In Paid Search: Navigating The Digital Landscape In 2024
Trends In Paid Search: Navigating The Digital Landscape In 2024
 
5 Public speaking tips from TED - Visualized summary
5 Public speaking tips from TED - Visualized summary5 Public speaking tips from TED - Visualized summary
5 Public speaking tips from TED - Visualized summary
 
ChatGPT and the Future of Work - Clark Boyd
ChatGPT and the Future of Work - Clark Boyd ChatGPT and the Future of Work - Clark Boyd
ChatGPT and the Future of Work - Clark Boyd
 
Getting into the tech field. what next
Getting into the tech field. what next Getting into the tech field. what next
Getting into the tech field. what next
 
Google's Just Not That Into You: Understanding Core Updates & Search Intent
Google's Just Not That Into You: Understanding Core Updates & Search IntentGoogle's Just Not That Into You: Understanding Core Updates & Search Intent
Google's Just Not That Into You: Understanding Core Updates & Search Intent
 
How to have difficult conversations
How to have difficult conversations How to have difficult conversations
How to have difficult conversations
 
Introduction to Data Science
Introduction to Data ScienceIntroduction to Data Science
Introduction to Data Science
 
Time Management & Productivity - Best Practices
Time Management & Productivity -  Best PracticesTime Management & Productivity -  Best Practices
Time Management & Productivity - Best Practices
 
The six step guide to practical project management
The six step guide to practical project managementThe six step guide to practical project management
The six step guide to practical project management
 
Beginners Guide to TikTok for Search - Rachel Pearson - We are Tilt __ Bright...
Beginners Guide to TikTok for Search - Rachel Pearson - We are Tilt __ Bright...Beginners Guide to TikTok for Search - Rachel Pearson - We are Tilt __ Bright...
Beginners Guide to TikTok for Search - Rachel Pearson - We are Tilt __ Bright...
 

CAR Example1.doc

  • 1. 15869 CORRECTIVE ACTION REPORT NAME: Jane Doe Employee ID: 004755 JOB TITLE: Cashier EMPLOYMENT DATE: November 4, 2016 STORE #: 999 DATE: June 4, 2019 PREVIOUS WARNINGS (dates and nature of offence): CAR # 15818 October 12, 2018 Verbal Warning – Late for scheduled shift CAR # 15827 December 23, 2018 Written Warning – Late for scheduled shift CAR # 15839 February 17, 2019 1-day suspension – Late for scheduled shift CURRENT INFRACTION: Late for scheduled shift – 8 to 4:30 on Sunday June 2, 2019. SUMMARY OF CIRCUMSTANCES SURROUNDING THE INFRACTION: Jane was an hour late for her scheduled shift on Sunday June 2nd. Her shift was to start at 8am and she did not arrive until 9am. When questioned, Jane stated that she slept in. ADDITIONAL COMMENTS: It is Jane’s responsibility to show up for scheduled shifts on time. Any future incidents of similar nature may result in more severe corrective action, up to and including termination. ACTION TAKEN: WARNING ________ SUSPENSION 3-days TERMINATION: _____ (check one) _______________________ _________________________ EMPLOYEE’S SIGNATURE (acknowledging receipt) MANAGER’S SIGNATURE *note – manager should sign last _______________________ _________________________ SHOP STEWARD/WITNESS(Signature) MANAGER (print name) _______________________ SHOP STEWARD/WITNESS (print name) Distribution of Copies: 1. Original - Retain at Store [personnel file] 2. Copy - Employee 3. Copy - [shop steward]