Notice of Disciplinary Action

Store Number
Employee Name
First Last
Date of Notice
MM slash DD slash YYYY
Type of Problem or Violation:
If other:
Date of Occurrence
MM slash DD slash YYYY
Details of Occurrence (Include description of impact on Company):
Corrective Action to be Taken:
First Day of Suspension
MM slash DD slash YYYY
Last Day of Suspension
MM slash DD slash YYYY
Expected Improvement (Include a clear statement as to the consequences of failing to improve):
Employee's Statement (Use additional paper if necessary):
By signing this notice, I am acknowledging that I have been counseled about my inappropriate conduct and informed of consequences if improvements are not made.
Date
MM slash DD slash YYYY