FLORIDA COMMUNITY COLLEGE AT JACKSONVILLE



-47625161290SICK LEAVE POOL MEMBERSHIP APPLICATION - FACULTY00SICK LEAVE POOL MEMBERSHIP APPLICATION - FACULTYEmployee Name (please print): ___________________________________________________PID Number: ______________________ Work Location: ____________________________ Work Phone Number: _______________ Job Title: _________________________________To be eligible Faculty must meet the criteria by the first pay date in March or September for an effective date the first workday in April or October respectively. I hereby apply for membership in the Florida State College at Jacksonville Sick Leave Pool. I understand that I must be employed in a full-time position with the College for at least one year to be eligible to join and have a sick leave balance of at least 80 hours. I certify that I have read and understand the rules and procedures for the sick leave pool, and I agree to the terms and conditions required. I request that 16 hours of my accrued sick leave be transferred to the sick leave pool._________________________________________ _____________________________Employee’s Signature DateCompleted forms should be returned to the Office of Human Resources in one of three ways: by mail to 501 W State Street, Suite 101, Jacksonville, FL 32202, emailed to benefits@fscj.edu or faxed to (904) 632-3329. If you email or fax your documents, you do not need to send the originals. This application must be received by the close of business on May 5, center84455FOR HUMAN RESOURCES USE ONLYSick leave balance:__________S L P deduction: -16New sick leave balance:__________Processed date:__________Processed by:__________00FOR HUMAN RESOURCES USE ONLYSick leave balance:__________S L P deduction: -16New sick leave balance:__________Processed date:__________Processed by:__________ ................
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