MIDDLE TENNESSEE STATE UNIVERSITY
NON-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 30th, 2015.
Name _______________________________________
M # _________________________________________
Department ___________________________________
Job Title _____________________________________
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 Non-Faculty Sick Leave
Bank Plan. I understand that this membership is subject to the MTSU NonFaculty 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 _________