VILLAGE OF PINEHURST APPLICATION TO RECEIVE SHARED LEAVE
Please complete all of the information below and submit to your Department Director. Employee Name _________________________________________________ Department _____________________________________________________ Total Number of Leave Hours Requested ______________________ Employee Statement: This is to request participation in the Village of Pinehurst’s shared leave program. I have experienced an extreme personal emergency or catastrophic event that requires my absence from work. I am not receiving Workers’ Compensation benefits nor do I plan to seek subrogation from a third party for the leave time. All of my sick, vacation and compensatory leave have been exhausted and I am requesting donated shared vacation leave hours as specified above. I authorize the Human Resources Director to release a request to Village of Pinehurst employees for donated leave based on my current situation.
____________________________________ Requesting Employee’s Signature/Date
Department Director Comments: ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ____________________________________ Department Director Signature/Date
Review Committee Approval and Date: _______________________________________________________
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