| Name of Member: | |
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| Number of Days Eligible: | |
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| Number of Days Requested: | |
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| Reason for Requesting Leave: | |
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This form must be submitted to the District Office. |
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PLEASE DO NOT WRITE BELOW THIS LINE |
Date Request received by District Office _________________________________ |
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This request has been reviewed by the Sick Leave Bank Committee and has been: |
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__________ | Approved | | | | __________ | Denied |
If denied, state reason: ________________________________________________ |