RESIGNATION/RETIREMENT FORM

Human Resources Department
Mt. Diablo Unified School District

1936 Carlotta Drive, Wing A, Concord, CA 94519-1397

Phone (925) 682-8000

Fax (925) 676-4092
RESIGNATION/RETIREMENT FORM
Employee First Name*
Employee Last Name*
Employee ID*
I am a:*

Certificated Employee (e.g. MDEA, MDSPA, Teacher Subs)Classified Employee (e.g. CST, CSEA, TEAMSTERS)
I am submitting this form to:*

Retire from MDUSDResign from MDUSD

Cell Phone Number*
Forwarding Address, City, State, Zip Code*
Work Location *
Position Title/Grade/Subject*
Supervisor Email*
example@example.com
Confirm Supervisors Email*
example@example.com
Site/Department*
Please Choose One:*

Adult EdCSTCSEADMA CertificatedDMA ClassifiedMDEAMDSPATEAMSTERSOTHER
Are you a School Bus Driver?*

YesNo
Do you have a position that works with Special Education students primarily? (Example: Special Education Teacher, Special Education Assistant, etc)*

YesNo
Do you have Electronic School Board (ESB) access?

YesNo
I hereby RETIRE from my position effective
Please Indicate Your Last Day Worked

MonthDayYear
Date
I understand that I must be eligible to retire with CalPERS or CalSTRS and meet the requirements outlined in the Bargaining Agreement or other applicable Agreement (“Agreement”) for your Association checked above. If you do not meet the requirements in the Agreement, you may still be eligible to retire with CalPERS or CalSTRS but must resign from the District and will not be eligible for retiree benefits.*

Clear
I hereby tender my RESIGNATION from my position effective
Please Indicate Last Day Worked

MonthDayYear
Date
Reason For Resigning

Moving Out of the AreaMedical/Caregiver ResponsibilitiesFurther Education/TrainingAccepted a Position Elsewhere for:Higher Salary SchedulePromotional OpportunityOther
If Marked Other (Please Explain)
Additional Comments (Optional)
I understand and agree that if I am resigning that my resignation is irrevocable.*

Clear
Date*

MonthDayYear
Date
I acknowledge that any payout for accrued but unused vacation time will be issued on the 10th day of the month following my separation date. The payout will be calculated based on my base rate of pay. (CSEA Employees Do Not Accrue Vacation & Are Paid Out Monthly)*

Yes
Forwarding/Personal Email Address*
example@example.com
MDUSD Email Address*
example@example.com
(HR Classified) Processed By:
Should be Empty:

Human Resources Department

RESIGNATION/RETIREMENT FORM