Voluntary Shared Leave Program
Donating or Transferring Leave
I hereby request permission to participate in the Shared Leave Program by donating or transferring leave as
follows:
Transferring Leave From
Employer: _________________________________________________________
Employee: _________________________________________________________
Employee ID Number: _______________________________________________
Phone Number: ____________________________________________________
Amount of Leave Transferring:
Hou
rs of Annual Leave ________ Hours of Bonus Leave _________ Hours of Sick Leave* _________
*Up to 40 hours of sick leave unless it is an immediate family member
Transferring Leave To
Employer: _________________________________________________________
Employee: _________________________________________________________
Employee ID Number: (HR will complete)_______________________________
Phone Number: ____________________________________________________
Any additional unused donated leave will be returned to the donor and credited to the leave account from which it
was
donated. It will be returned to the donor on a pro rata basis. A fraction of one hour will not be returned to an
individual donor.
Employee Transferring Leave Signature: ______________________________________ Date: ________________
Director of Human Resources __________________________________________ Date: ________________
Controller: ________________________________________________________ Date: ________________
Revised 7/17/2017
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