Rescind Of Resignation Request Form printable pdf download

RESCIND OF RESIGNATION REQUEST FORM

__________________

DATE:

Department of Administrative Services

TO:

Statewide Human Resources Management

450 Columbus Blvd. Hartford, CT 06103

Fax: (860) 622-2915

FROM:

_____________________________________

Social Security #: __ __ __ - __ __ - __ __ __ __

Print Full Name

____________________________________

Employee ID #: __ __ __ __ __ __

Mailing Address (include Apt. #)

____________________________________

Effective date of Resignation: __ __ /__ __ /__ __

City, State, Zip Code

M M

D D

Y Y

____________________________________

______________________________________

Former Name, if any

Last Employing Agency (do not abbreviate)

Effective today, I wish to rescind my resignation from an Executive Branch agency in State of

Connecticut (“State”) service. I understand as a permanent, classified employee, I am allowed to

take this action provided I do so within one year from the date of my resignation in good standing. I

also understand I am eligible to return to State service in any class(es) in which I had previously

attained permanent status without examination as long as I am rehired into this classification within

two years from the effective date of my resignation.

I further understand:

•

General Letter No. 177 (found on-line at

- Human Resources page - Business

Rules and Regulations Section – General Letters) discusses the Rescind of Resignation Procedure

and authorizes the assignment of certain privileges provided I am rehired within prescribed

timeframes and provided I meet established criteria for receiving such privileges.

•

I must have been a permanent, classified employee in State service at the time of my resignation

from an Executive Branch agency in order to rescind my resignation.

•

I must have resigned in good standing in order to rescind my resignation.

•

I must have resigned within one year from the date of this request in order to rescind my resignation.

•

My name will not appear on any Reinstate or SEBAC list(s) as only laid-off State employees are

eligible for this benefit. Therefore, I understand the State of Connecticut is not obligated to notify me

of openings in positions for which I qualify under this procedure nor is the State of Connecticut under

any obligation to rehire me.

•

If the requirements for position(s) in which I had previously attained permanent status have changed,

I must meet the new training and experience requirements as outlined on the (current) job

description(s) in order to qualify for position(s) in the(se) classification(s).

•

The DAS-Statewide HR Management will review the information I have provided above and approve

or deny this request accordingly.

•

DAS-Statewide HR Management will notify me of the status of my request via First Class Mail.

•

Privileges under General Letter No. 177 are applied at the time of reinstatement to a permanent

State of Connecticut position and are not extended to any future appointments.

Signed:

_____________________________________

Signature of Former State of CT Employee

Rescind Of Resignation Request Form

Related Articles

Related forms

Related Categories