Fillable Form IV.D.1: Overload Course Deferral Request: Use this (Lone Star College System)

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Form IV.D.1: Overload Course Deferral Request: Use this (Lone Star College System)

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The Form IV.D.1: Overload Course Deferral Request: Use this (Lone Star College System) form is 4 pages long and contains:

  • 10 signatures
  • 6 check-boxes
  • 45 other fields

Country of origin: US
File type: PDF

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Page 8 of 11
Form IV.D.1: Overload Course Deferral Request
Use this Form to request that your compensation be deferred for any overload courses. This form
must be submitted before the first day of class of the overload course.
Name:
Last First Middle Initial
Employee ID:
OVERLOAD COURSE INFORMATION
Course Number: Location:
Course Name:
Semester: Year: Date Class Begins:
I consent to the deferral of all compensation for the above-indicated courses. I understand that any
changes to my election to defer compensation for the above course must be submitted prior to the
first day of class. I have read and agree to follow the policies and procedures found in the Board
Policy Manual Section IV.D.1.(i). and applicable Chancellor Procedures.
Signature Date
For Office Use Only
DEAN OF INSTRUCTION:
Date Request Received:
Approved Denied
Signature Date
PAYROLL:
Date Request Received:
Date Deferral Effective:
Signature Date
Printed Name
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signature
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Page 9 of 11
Form IV.D.2: Leave Semester Request
Use this Form to request a Leave Semester. This form must be submitted at least two semesters
prior to the requested leave semester.
1
This form may be submitted alongside the faculty member’s
final overload course deferral request, making them Leave Semester-eligible.
Name:
Last First Middle Initial
Employee ID:
Semester Requested:
Term: Year:
Signature Date
For Office Use Only
DEAN OF INSTRUCTION:
Date Request Received:
Signature Date
VICE PRESIDENT-INSTRUCTION
Date Request Received:
Approved Denied
Signature Date
PAYROLL:
Date Request Received: Date Processed:
Signature Date Printed Name
1
This Form and the Faculty Member’s request to defer their last extra course assignment to become Leave Eligible
may be submitted simultaneously.
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signature
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Page 10 of 11
Form IV.D.3: Leave Semester Approval
Date
Dear ,
I hereby Approve Deny your request to take a Leave Semester in
Date Received
.
Term Year
Signature of Vice President of Instruction
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Page 11 of 11
Form IV.D.4: Payout Request
Use this Form to request a cash payout.
Name:
Last First Middle Initial
Employee ID: Requested Payout Amount: $
I am requesting a cash payout in the above amount, to be paid out of my Leave Bank Account with
my next regularly scheduled paycheck after processing is complete.
Signature Date
For Office Use Only
PAYROLL:
Date Request Received: Date Processed:
Signature Date Printed Name
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Form IV.D.1: Overload Course Deferral Request: Use this (Lone Star College System)

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Completed 6 October 2020

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