Voluntary Separation Request
Please complete the information below and email to Diane Forgione at
Name: Employee classification: Faculty Classified
Department: Supervisor:
Proposed date of Separation:
Selection: Please check one: 2-months’ salary or $650 Benefit subsidy for 18 months
By signing below, the employee specifically acknowledges the following:
1. I am volunteering of my own free will for a voluntary separation incentive and that no
coercion or intimidation was exerted upon me.
2. I have not received a specific notice of involuntary separation for misconduct or
unacceptable performance.
3. I understand that the final authority to approve or deny any plan application resides with the
University President. I understand that final decisions on plan applications are not subject to
4. I understand I will be notified of the outcome of my application; the notification will include a
final offer of the separation including an Incentive Agreement.
Signed: Date:
Received - Office of Human Resources:
Reviewed by VP of Human Resources:
Reviewed by Supervisor:
Final Decision Date: Approved Denied
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