Employee Exit Form

Employee Exit Form

INSTRUCTIONS (Please read before completing the form):

1. Employee shall notify their immediate manager of their resignation or retirement prior to or concurrent with notification to Human Resources.

2. At the completion of this form, a District Property Separation Checklist and Employee Separation Survey will be provided (if applicable).

3. Contact Benefits at hrbenefits@mtsac.edu to schedule a meeting to review your applicable health & welfare benefits.

To obtain detailed information regarding your retirement, contact the appropriate agency listed below:

a. CalPERS: http://www.calpers.ca.gov/ or call 888-225-7377

b. CalSTRS: http://www.calstrs.com/ or call 800-228-5453

c. National Benefits Services (NBS) (FICA Alternative Retirement Plan): www.nbsbenefits.com/403b or call 1-800-274-0503

In accordance with AP 7350, resignations accepted by the College President/CEO are final and may not be rescinded.

Any questions regarding this form, please contact hroperations@mtsac.edu.

Employee A#*

First Name*

Last Name*

Employee Work Email*

Classification*

Select

Position Title*

Manager Name*

Manager Email*

Department*

Major Division*

Select

Separation Type*

Retirement

Resignation

Resignation Reason*

Select

The last day of work will be your last day of paid status with Mt. SAC.

The last day of work will be your last day of paid status with Mt. SAC before entering retirement.

Last Date of Work*

Do you have more than one position with the District in another capacity (e.g. adjunct, temporary employment)?*

Yes

Please list your additional positions*

If there is any additional information you wish to include, please attach it here.

This is not a requirement

Drag and drop files here or

I understand that in accordance with AP 7350, resignations accepted by the College President/CEO are final and may not be rescinded.

By checking the box, I certify the information furnished herein, and I hereby give notice of my separation as a Mt. San Antonio Community College District employee.*

Send me a copy of my responses

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