Fill - Free fillable Volunteer State Community College Sick Leave Bank Enrollment (Volunteer State Community College) PDF form

Volunteer State Community College

Sick Leave Bank Enrollment Application

( ) Faculty Sick Leave Bank ( ) Non-Faculty Sick Leave Bank

Employee Name:

V Number:

Social Security No.:

Department:

Position:

By my signature below, and upon acceptance of my membership by the Trustees, I acknowledge the

following:

A. I am aware of the provisions of the Sick Leave Bank and do hereby relieve Volunteer State

Community College from any liability as a result of actions by the Trustees.

B. I am aware of the initial assessment of fifteen (15) hours from my accumulated sick leave

balance.

C. I understand this donation and subsequent assessments are final and may not be returned

unless the bank is dissolved.

D. If it is necessary for the Trustees to assess additional days, I as a member may refuse;

however, my membership in the Sick Leave Bank will be terminated.

E. I understand this authorization will remain in effect for this and subsequent years unless I

cancel in writing.

_____________________________________ __________________________

Employee Signature Date

For Office Use Only: (record all data in hours)

Membership accepted

Membership denied*

Employee Sick Leave Bank Hours:

Date Certified:

*Reason for denial:

Approved by Chair of Sick Leave Bank Committee

Date

Rev. 9/28/12

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Volunteer State Community College Sick Leave Bank Enrollment (Volunteer State Community College)

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