Sick Leave Bank Donation/Revocation Form

Sick Leave Bank Donation/Revocation Form

(Enrollment/revocation changes may only be submitted annually during the open enrollment period)
Name (of Employee Donating Leave)*

First NameLast Name
Rank/Title*
Department*
WIU ID*
Office Phone*
Please enter a valid phone number.
WIU Email*
example@example.com
Percent Appointment*
Start Date*

MonthDayYear
Date
I am...*

Enrolling/changing optionsRevoking membership/leaving sick bank
Enrollment - Donation will be deducted from your designated leave balance the latter part of June*

Initial EnrollmentCurrently in bank, changing type of leave to be donated
I am donating one (1) day of (check one):*

Sick Leave - (Donated sick leave will first be transferred from cumulative, non-compensable sick leave, if available.)Vacation
Leave Balances*
I have read and understand the Voluntary Sick Leave Bank Policy and voluntarily donate the above day. I will have a minimum of 10 leave days (sick and vacation combined) available for personal use after this donation. I understand I will be able to request withdrawal of days from the bank according to the policy should it become necessary.
Signature

Clear
Revocation

Membership in the Sick Leave Bank continues from year-to-year with an annual reduction in leave until/unless the member submits this revocation form to discontinue membership.

I hereby revoke my membership in Western Illinois University's Sick Leave Bank.
Signature

Clear
Should be Empty: