Document 3e6Om0JOkpMkzzLJja127NVja

J .A % 35 v ABSENCE PATKENT APPROVAL FORM <T h ** m i r n L Krjue C. . F . f;r/sifst Job Classification ^ m'r w fe*^ D"ePpt* ^(.p t^v / Payroll No* O ^ Z V v */ .. *; Tears of Service Birthdate -- * x ^ & Completed________ f/ Nature of Absence A/^ ^ A ` Ss/ /- / -s ^ r? * ^ ^ f/i C <**- r* > / 1. ;How many days of extended absence does the employee qualify for under the schedule! 2* How many days of intermittent or extended paid absence other than for military training, jury duty, jury witness, funeral, elections and no work has the employee been paid for in the past twelve months? 3. How many full days of extended paid absence has the enqoloyee received during the past twelve months up to the first date shown in 6? (Include full pay and half pay days) __ U. Total number of days of extended absence remaining? (Subtract 2 and 3 from l) ______ 5, . Date present absence began, 6. Approval is requested fromthrough 7. Number of work days requested in 6? 8, If the number in 7 is larger than the number shown in U, fill in a) and b), a. Reason for request beyond schedule: b. Number of days of paid absence in each of the last five years: 1955 ___ 1956 ___ 1957 1958 1959 Processed "Salary Administrator Submitted by Approval for payment 1 President J USE THIS SECTION OULT IP HALF PAT IS INVOLVED 1. Place employee on half pay beginning (employee may remain on half pay within policy through. .) r- . _^ , . 2* Remove employee from half pay status and return to full pay effective O *' J " & 1 PRIVILEGED AND "CONFIDENTIAL MATERIAL SUBJECT TO PROTECTIVE ORDER" UCC 075071