General Release And Waiver (Page 7 of 7) in pdf

Self Select Request for Separtion

APPLICATION FOR SELF-SELECT VOLUNTARY SEPARATION

ADD WHERE APPROPRIATE: [IN CONJUNCTION WITH THE INVOLUNTARY SEPARATION PROGRAM]

I hereby VOLUNTARILY APPLY to be considered for termination from employment with [Contractor]

(“Employer”) [ADD WHERE APPROPRIATE: “in conjunction with the Involuntary Separation Program”]. I

am selecting this option of my own free will after having had an opportunity to review the terms,

conditions and consequences of designating myself for the “self-select” process. IF APPROPRIATE, ADD:

[I understand that if there are insufficient volunteers, then I may be considered for involuntary

termination, and therefore, by voluntarily applying to be considered for termination, I will be assisting

the Employer in determining who should be terminated.] I agree that the Employer has no obligation to

reemploy me in the future and I understand that I do not have rehire preference rights under Section

3161 of the National Defense Authorization Act for Fiscal Year 1993.

I understand that this Request is subject to the approval of the Employer and, if approved, my

employment will be terminated subject to the same terms and conditions applicable to all other

participants in the Self-Select Voluntary Separation [in Conjunction with the Involuntary Separation

Program.] The separation package has been explained to my satisfaction.

I agree that, if I am selected by the Employer to participate in the Self-Select Request for Separation

Program [ADD WHEREAPPROPRIATE: “in Conjunction with the Involuntary Separation Program”] and I

then become employed by the Department of Energy (DOE) or the National Nucelar Security

Administration (NNSA), the Employer or any other contractor or subcontractor to the DOE or NNSA for

work performed under a contract with the DOE or NNSA within a period of one (1) year from the date of

my separation, I may be required to repay a portion or all of the severance payments which I received

pursuant to my participation in the Self-Select Voluntary Separation [ADD WHERE APPROPRIATE: “in

Conjunction with the Involuntary Separation Program, and I agree to such payment”]. Examples of

employment that may require me to repay severance include, but are not limited to, work under

contracts or subcontracts with the DOE or NNSA such as temporary employment contracts, service

contracts, general task order assignments, indefinite quantity contracts, basic ordering agreements, and

consultant contracts. However, my obligation to repay severance would not be triggered by

employment with a company that provides supplies, equipment, materials, commodities, or services for

a DOE or NNSA facility under a fixed priced contract or purchase order and whose primary business

activities are not in support of such DOE or NNSA facility.

I have read this Request to terminate employment as part of the Self–Select Voluntary Separation

[ADD WHERE APPROPRIATE: “in Conjunction with the Involuntary Separation”] Program and agree to

abide by the terms set forth herein if my Request is accepted:

Employee

Name: ___________________________________

Number:_______________

(Print Last Name, First Name, MI)

Signature: __________________________________

Date: __________________

General Release And Waiver Page 7