Employee Resignation Form

Account*
Employee Name*
Date
MM slash DD slash YYYY
Effective Resignation Date*
I have decided to resign from my employment, effective:
MM slash DD slash YYYY
I understand that I will be paid all money (monies) due me in accordance with company policy. Further, I understand that my group insurance coverage, if applicable, terminates.

I have reported all work-related accidents that may have occurred while I was employed by the company and to the best of my knowledge I am not currently suffering from any work-related injury or illness. Further, I brought any complaints that I may have had regarding any supervisors or co-workers or their treatment of me to the company’s attention, and any such complaints have been resolved.
Reason for Resignation*
I have tendered my resignation because of the following reasons:
Employee Signature*
I have siged this form voluntarily.
Address to which W2 should be sent:*
Street Address Address Line 2 City State Zip
Supervisor Name
Date
MM slash DD slash YYYY
Supervisor Signature*

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