Request Form - MGL Chapter 31, §60A

	I hereby request, pursuant to MGL Chapter 31, §60A, that my employment not be terminated as a member of the _______________ (Reserve) (Intermittent)
						(City or Town)
_______________Force.
     (Fire or Police)

	I understand that this request is irrevocable.  I understand that, as a result of filing this request, my name will no longer be submitted to the

___________________  _______________________ Force for appointment as
	(City or Town)			(Fire or Police)

a regular, full- time Police Officer or Firefighter.  I further certify that I understand that I may not withdraw, cancel, invalidate, annul, void, or in any other manner, nullify this request and I hereby permanently and irrevocably abandon any right to appeal I may have to seek appointment from my present reserve or intermittent position to the above employment.

						________________________________
								    Signature

						________________________________
								   Print Name

Dated:    ____/____/____

Commonwealth of Massachusetts			__________________________, ss.

_______________________________ personally appeared before me this ________ day of ________________________, ________, and made oath that the above signature was (his) (her) free act and deed.

						____________________________________
								Notary Public

						My Commission Expires ____/____/______

HRD Form 60A