Employee name: __________________________ Department: ___________________
Date of hire: ______________________________ Supervisor: ____________________
| Item | Quantity | Cost | Total Cost | Employee's initials |
|---|---|---|---|---|
[] Uniforms | ||||
[] Shoes | ||||
[] Short sleeved shirts | ||||
[] Long sleeved shirts | ||||
[] Pants | ||||
[] Jacket | ||||
[] Safety items | ||||
[] Tools | ||||
[] Other: | ||||
By signing below, I acknowledge that I have received all of the items initialed above and agree to return all items in good condition upon termination of employment or have the entire cost deducted from my final paycheck. In the case of uniforms, which will not be returned, if my employment is ended before I complete my orientation period of 90 days, the entire cost of the uniforms will be deducted from my final paycheck. If my employment is terminated or uniforms are lost or damaged before the completion of one year, a prorated portion of the cost of the uniforms will be deducted.
Employee signature: _______________________________ Date: __________
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