Disciplinary Notice

Date:

Employee:

Department:

[___] Written Warning [___] Final Warning

1. Statement of the problem: (violation of rules, policies, standards, practices, or unsatisiactory performance)

2. Prior, if any, discussion or warnings on this subject, whether oral or written. (List Dates):

3. Company policy on this subject:

4. Summary of corrective action to be taken by the company and/or employee:

5. Consequences of failure to improve performance or correct behavior:

6. Employee statement: (continue on reverse, if necessary)

________________________

Employee

_________________________

Management