SICK LEAVE BANK DONATION FORM
FOR UNIT 1 EMPLOYEES ONLY
8008 Marlboro Pike Forestville, Maryland 20747 (301) 736-2700 Fax (301) 568-8900
The following are not eligible to join the PGCEA Sick Leave Bank:
Non Unit 1 Employee Retire Rehire Substitute Teachers Home and Hospital Per Diem
Unit Date:
(Date of Hire or Date Transferred to PGCEA Unit)
Which is currently applicable to you? CHECK ONE:
New Hire-It is within 7 months of hire date-(Eligible to join in 7
th
month, PGCEA will hold app. for processing)
Unit Transfer/Reassignment-(Eligible to join within 30 days of unit transfer/reassignment date)
Hired/transferred more than 7 months ago (Must join during the OPEN ENROLLMENT period JUL 1-SEP 30)
Employee #
(EIN)
Or
Social Security #
First MI
Last
Address
City State Zip
Contact Phone Non-Work Email
I hereby apply for membership in the PGCEA Sick Leave Bank and I hereby donate two and ½ days (2.5) of my earned sick leave to the Bank to
provide for such membership. I authorize continuous annual deductions from my earned sick leave in future school years as established annually
by the rules committee to provide for the continued operation of the Sick Leave Bank. I understand that I may withdraw from the Sick Leave Bank at
any time by submitting such a request, in writing to the Sick Leave Bank Approval Committee. In signing this authorization I acknowledge receipt of a
copy of the PGCEA Sick Leave Bank Rules. I understand that if transferred to another unit within the PGCPS System, my bank membership will be
automatically transferred and I will be subject to all rules, terms and conditions of the new bank effective the date of transfer.
Signature of Employee Date
Sick Leave Bank membership is not valid until approved by the Sick Leave Bank Approval Committee and the Board of Education
Instructions:
Sign and return completed donation form.
Confirmation of receipt will be sent via email from PGCEA and your application will be forwarded to PGCPS for final processing.
Incomplete applications (no signature, email address, EIN or incomplete SSN) will cause processing delays.
See all Sick Leave Bank Rules at www.pgcea.org
*KEEP A COPY OF THIS FORM FOR YOUR RECORDS*
Official Use Only
PGCEA Sick Leave Bank Committee PGCPS Instructional Personnel Use Only
____________________________________________________
(Authorized Signature)
Received: _____________________
Eligible: _____________________
Letter Sent: _____________________
Revised 7/2013
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