Employee Separation Notice
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3EMPLOYEE SEPARATION NOTICE
STATE OF LOUISIANA
DEPARTMENT OF NATURAL RESOURCES
_____________________________________
(Department/Division)
Employee Name: ______________________________
Personnel No.: P_______________________________
Job Title: ____________________________________
Date: _______________________________________
TO: ____________________________
(Supervisor)
Please accept my:
_______ Resignation
_______ Retirement
_______ Transfer to another state agency
If so, please list the agency _____________________________________________
which is to become effective the close of business on ______________________________________.
My reason for leaving is______________________________________________________________
_________________________________________________________________________________.
Signed, _________________________________
(Employee)
ACCEPTED: ____________________________
DATE: ______________________
(Supervisor)
ACCEPTED: ____________________________
DATE: ______________________
(Appointing Authority)
Rev: 01/2016
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