MIDDLE TENNESSEE STATE UNIVERSITY
FACULTY SICK LEAVE BANK
APPLICATION FOR MEMBERSHIP
OPEN ENROLLMENT OCTOBER 1 THRU OCTOBER 30, 2015
Please complete and return to Human Resource Services (no box number necessary), by 4:30 p.m. Friday, October 30 th
, 2015.
Name _____________________________________________________
M # __________________________________________
Department ________________________________________________
Academic Rank or Position ____________________________________
In accordance with Senate Bill No. 98, which provides for the creation of sick leave banks at institutions within the Tennessee Board of Regents
System, this is to request membership in the MTSU Faculty Sick Leave
Bank Plan. I understand that this membership is subject to the MTSU
Faculty Sick Leave Bank Guidelines, as administered by the Trustees, and acknowledge that a copy of the guidelines has been made available to me.
This is to authorize the trustees to transfer the equivalent of two (2) days of my sick leave to the Sick Leave Bank.
_____________ ____________________________________________
Date Signature
(You will be notified if you had insufficient leave to join the bank.)
Human Resources Services Office Use Only
Initial Sick Leave Assessed _________
Effective Date of Membership _________