WWW.ASA.EDU
DOWNTOWN BROOKLYN
81 Willoughby Street
Brooklyn, NY 11201
Tel.: 718 - 522-9073
MIDTOWN MANHATTAN
1293 Broadway/One Herald Center
New York, NY 10001
Tel.: 212-672-6450
ACKNOWLEDGMENT OF RECEIPT FORM - NY
(NY Paid Safe and Sick Leave Law Information and
ASA Safe and Sick Leave Policy)
___________________________________________
Employee Signature
___________________________________________
Date Signed
I, _______________________________________________________________(Last Name, First Name),
acknowledge that I have received, read and understood ASA College Safe and Sick Leave Policy.
I further acknowledge that I have received the “Notice of Employee Rights” pursuant to New York
Citys Paid Safe and Sick Leave Law.
EMPLOYEE ID#
Last, First
CURRENT EMPLOYMENT INFORMATION
NAME: ___________________________________________________________________
LOCATION: ____________________ DEPARTMENT: __________________________________________________________________
TITLE: ___________________________________________________________ REPORTS TO:_________________________________
FT FTE PT FT INSTRUCTOR FT-N ADJUNCT ADJUNCT-FTE
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