San Francisco Department of Public Health
Grant Colfax, MD
Director of Health
City and County of San Francisco
London N. Breed
Mayor
To:
Human Resources Department- Operations Unit
101 Grove St. Room 210
San Francisco, Ca. 94102
Re:
Voluntary Resignation
From: Employee Name: __________________________________
DSW: ____________________
I voluntarily resign/retire from my position as a ____________________________
(Job Class and title)
As of Close of Business (COB) _______________
(last day of employment)
I understand that, if I am qualified, I shall be compensated for any vacation hours earned but not used.
Reason for resignation: _____________________________________________________________________
I understand that this resignation refers to all other employment, which I hold at any other Department of Public
Health location, including any as-needed positions or position from which I am currently on leave. My other
employment is in job classification and location:_______________________________________________
Signature: ____________________________
Home Address: __________________________________
Date: ________________________________
___________________________________
-------------------------------------------------------------------------------FOR SUPERVISOR’S USE ONLY:
☐
This is to certify that the above employee’s services have been satisfactory
☐
This is to request that the above employee’s services be marked unsatisfactory and that his/her future
employability be determined by the Civil Service Commission. I understand that this request will not be
considered unless supporting documentation is attached.
Name of Supervisor: _____________________________ Signature: ________________________________
Department: ____________________
Phone number: __________________
SFDPH │101 Grove Street, Room 210, San Francisco, CA 94102
Date: ____________