PAYROLL COPY
UNIVERSITY OF GUAM
Leave Application
NAME (First, Middle, Last)
TYPE OF LEAVE
REQUESTED [HRS]
PAY STATUS [Calculates Automatically]
REASON
APPROVED
APPROVED
DISAPPROVED
DISAPPROVED
Number of Hours with Pay:
FROM (Hour, Month, Day, Year)
FROM (Month, Day, Year)
FROM (Month, Day, Year)
REMARKS (State limitations, if any)
NAME OF PHYSICIAN (Print or type) SIGNATURE OF PHYSICIAN
TO (Hour, Month, Day, Year)
TO (Month, Day, Year)
TO (Month, Day, Year)
HOSPITALIZED: YES NO
TOTAL HOURS PREPAID
Without Pay: Total Number of Hours:
COLLEGE / UNIT
DOCTOR’S SICK LEAVE CERTIFICATION
I certify that the above-named person was under my professional care or quarantined during the period stated below.
APPLICATION OF PREPAYMENT OF LEAVE
DATE
NOTE: For rules and regulations pertaining to absence from duty, refer to the appropriate personnel policies: (1) Government of Guam Civil Service Personnel
Rules and Regulations (classied employees), and (2) University of Guam Personnel Rules and Regulations (academic/non-classied employees).
I certify all statements made
herein are true and correct.
SIGNATURE OF EMPLOYEE DATE
DATE
DATE
NAME OF CHAIR/SUPERVISOR SIGNATURE
SIGNATURENAME OF APPROPRIATE ADMINISTRATOR
LWOP
V. 10.20.16
Sick
Jury
[ ] [ ] [ ] [ ] [ ] [ ]
[ ] [ ] [ ] [ ] [ ]
Annual
Military
Administrative
Bereavement
Maternity
Paternity
PPE: ___/___/___ [ ] hours
PPE: ___/___/___ [ ] hours
Parental
Other (specify)
UNIVERSITY OF GUAM
Leave Application
NAME (First, Middle, Last)
TYPE OF LEAVE
REQUESTED [HRS]
PAY STATUS [Calculates Automatically]
REASON
APPROVED
APPROVED
DISAPPROVED
DISAPPROVED
Number of Hours with Pay:
FROM (Hour, Month, Day, Year)
FROM (Month, Day, Year)
FROM (Month, Day, Year)
REMARKS (State limitations, if any)
NAME OF PHYSICIAN (Print or type) SIGNATURE OF PHYSICIAN
TO (Hour, Month, Day, Year)
TO (Month, Day, Year)
TO (Month, Day, Year)
HOSPITALIZED: YES NO
TOTAL HOURS PREPAID
Without Pay: Total Number of Hours:
COLLEGE / UNIT
DOCTOR’S SICK LEAVE CERTIFICATION
I certify that the above-named person was under my professional care or quarantined during the period stated below.
APPLICATION OF PREPAYMENT OF LEAVE
DATE
NOTE: For rules and regulations pertaining to absence from duty, refer to the appropriate personnel policies: (1) Government of Guam Civil Service Personnel
Rules and Regulations (classied employees), and (2) University of Guam Personnel Rules and Regulations (academic/non-classied employees).
I certify all statements made
herein are true and correct.
SIGNATURE OF EMPLOYEE DATE
DATE
DATE
NAME OF CHAIR/SUPERVISOR SIGNATURE
SIGNATURENAME OF APPROPRIATE ADMINISTRATOR
LWOP
V. 10.20.16
Sick
Jury
[ ] [ ] [ ] [ ] [ ] [ ]
[ ] [ ] [ ] [ ] [ ]
Annual
Military
Administrative
Bereavement
Maternity
Paternity
PPE: ___/___/___ [ ] hours
PPE: ___/___/___ [ ] hours
Parental
Other (specify)
FILE COPY
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Dr Lee Yudin, Dean
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Dr Lee Yudin, Dean
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