Outplacement request

First name

Last name

Date of birth

Street + postal code + city

Date of dismissal

Type of dismissal

Number of weeks' notice/severance pay

Reference salary: 1/12th of the gross annual salary (if 30 weeks or more notice)

Joint committee

Company or organization name

Street + postal code + city

First name of contact person

Last name of contact person

Contact person’s phone number

Contact person’s email

Contact person’s job title

(for social secretariats only)

Office

First name of case manager

Last name of case manager

Case manager’s phone number

Case manager’s email

Please note any remarks below that we should take into account