SICK LEAVE POOL APPLICATION
Please Print
Name: ________________________________ UWF ID#: ___________________________
Department: ___________________________ Extension: __________________________
Campus Address: ______________________________________________________________
I hereby apply for membership in the University's Sick Leave Pool. I have read and understand the terms and
conditions that apply to membership and I agree to follow the procedures established for participation in the
Sick Leave Pool. I understand that I am required to make an initial contribution of sixteen hours* of sick leave
and subsequent contributions, if necessary, not to exceed sixteen hours per year.
_____________________________________________ _____________________________
Employee's Signature Date
*N
umber of hours required for full-time employees.
The required number of hours for part-time employees is prorated based on employee's FTE.
Return to: Human Resources
Attendance and Leave
Bldg. 20E/Room 117L
Please do NOT write below this line
FOR SICK LEAVE POOL COMMITTEE USE ONLY
Verification
of the following information has been provided by Human Resources to establish eligibility for membership into
the University’s Sick Leave Pool.
Current Sick Leave Balance: _____________ (hours) as of _______________________.
Employee meets membership eligibility requirements: Yes No
Employee’s FTE: ____________ Hours Contributed: __________ Initial Contribution Date: ___________ Other: ____________
Membership Approval Date: ________________________
Comments:
__________________________________________________________________________________________________________
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__________________________________________________________________________________________________________
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_____________________________________ _______________________________
Sick Leave Pool Administrator Date
