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MAINTENANCE SICK LEAVE BANK SICK BANK WITHDRAWAL APPLICATION FORM Applicant Work Location Home Address Personnel Number Home Phone Nature of Accident Illness or Injury Date of Accident Illness or Injury Last day of work Date on which your personal/sick leave will expire Number of days requested Date you expect to return to work Applicant s Signature Supervisor s Signature Sick Bank Committee Disposition Date Application Received Date Action Taken Disposition of Application Approved Denied Number of Days Approved Start Date End Date Comments Authorized Signature PAYROLL DEPARTMENT DISPOSITION Gross Paid Check Date Hours Paid Pay Period Check Number Processed by Date Processed TO APPLICANTS APPLYING FOR THE SICK BANK Please complete the application form on the reverse side of this document including your name home address work location social security number home phone number the nature of the illness/injury the number of days requested and the date you expect to return to work. Those items preceded by an asterisk including the date of the illness/injury last day of work prior to accident/illness/injury and the date on which your personal/sick/vacation leave will expire are items which you must have verified by your supervisor. It is important that these items be accurate so consult with your immediate supervisor and school/dept. payroll person in order to ensure accuracy. It is important to attach a Doctor s Certificate which verifies your illness or injury. The Doctor s Certificate should be as clear as possible to explain the nature of the illness/injury and the anticipated length of recovery. The original completed signed application form and accompanying doctor s certificate should be sent to Jim Silvernale Business Representative Federation of Public Employees 1700 NW 66 Avenue Suite 100 Plantation FL 33313 The Sick Bank Committee will be convened on your behalf and you will be notified of the outcome. Those items preceded by an asterisk including the date of the illness/injury last day of work prior to accident/illness/injury and the date on which your personal/sick/vacation leave will expire are items which you must have verified by your supervisor. It is important that these items be accurate so consult with your immediate supervisor and school/dept. It is important that these items be accurate so consult with your immediate supervisor and school/dept. payroll person in order to ensure accuracy. It is important to attach a Doctor s Certificate which verifies your illness or injury. payroll person in order to ensure accuracy. It is important to attach a Doctor s Certificate which verifies your illness or injury. The Doctor s Certificate should be as clear as possible to explain the nature of the illness/injury and the anticipated length of recovery. The Doctor s Certificate should be as clear as possible to explain the nature of the illness/injury and the anticipated length of recovery. The original completed signed application form and accompanying doctor s certificate should be sent to Jim Silvernale Business Representative Federation of Public Employees 1700 NW 66 Avenue Suite 100 Plantation FL 33313 The Sick Bank Committee will be convened on your behalf and you will be notified of the outcome.

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