VOLUNTARY FURLOUGH
Reduction in Work Hours Without Pay
The City Manager has initiated a Voluntary Furlough Program. Attached is a copy of the Personnel
Policy and Procedure Manual section dealing with furloughs. If you wish to participate, please
indicate how many days you wish to be on unpaid furlough and your first and second choices of dates.
NAME:___________________________________________________________
TITLE:___________________________________________________________
SALARY:_________________________________________________________
# DAYS:__________________________________________________________
DATE(S)/1
ST
:______________________________________________________
DATE(S)/2
ND
:_____________________________________________________
HAVE YOU ACCUMULATED IN EXCESS OF 42 HOURS OF UNUSED COMP. TIME?
____ YES ____NO
WILL YOUR ACCRUED VACATION TIME EXCEED THAT ALLOWED FOR TWO YEARS ON
12/31 OF THIS YEAR? ____YES ____NO
I have read and understood the policy for voluntary furlough and I make this request on my own free
will. I also understand that any benefit or payroll deduction that is in effect at the time of the furlough
will be deducted from my check (if any) or I will make arrangements with Payroll and Personnel to
make those payments.
Employee’s Signature___________________________ Date:_____________________
SUPERVISOR’S COMMENTS & RECOMMENDATION:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________
Supervisor’s Signature___________________________ Date:_____________________
Department Head: Accept_____ Reject_____
Signature______________________________________ Date:_____________________
City Manager: Accept_____ Reject_____
(Only for furlough in excess of 30 calendar days)
Signature______________________________________ Date:_____________________
Form 1210.003
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