Republic of the Philippines

Department of Education
REGION I
PANGASINAN SCHOOLS DIVISION OFFICE II
BINALONAN, PANGASINAN

__________________
Date

LETTER OF INTENT TO RETIRE

LORNA G. BUGAYONG, PhD., CESO V

Schools Division Superintendent
Binalonan, Pangasinan

Sir:
I hereby apply for a retirement/separation from the Department of Education, this Division of
Pangasinan II effective _____________, and declare to the best of my knowledge the following:

Family Name: First Name: Middle Name: Employee Number:

Date of Birth: (mm/dd/yy) Age Upon Retirement:

Complete Mailing Address: Place of Birth:

Plantilla (District/School): Position Title:

Educational Attainment: Eligibility: Performance Rating:

I affirm that the information indicated above has been accomplished by me and is true and
correct.

Very truly yours,

_______________________________
 Republic of the Philippines
Department of Education
REGION I
PANGASINAN SCHOOLS DIVISION OFFICE II
BINALONAN, PANGASINAN

(Signature Over Printed Name of the Retiree)