Date Received. Game Management Unit Ranch #
Date Received. E. Disposition by the appropriate administrator or Joint Grievance Committee: (attach additional pages if necessary) Signature Date Sick Leave Pool Committee APPLICATION FORM PLEASE ATTACH PHYSICIAN'S STATEMENT Name Date In accord with Article VI, Sec. B of the Negotiated Agreement, I hereby request a Sick Leave Grant of days (contract days) for the following condition: Dates I expect to be (or have been) disabled: I have exhausted all my Accumulated Sick Leave (yes or no): Signature of Employee (or other family member-in case of necessity) SICK LEAVE POOL : Grant applications are made by submitting a letter of request to a member of the sick leave pool committee. Grants - the maximum grant to be awarded will be twenty (20) contract days per catastrophic or disabling condition. Catastrophic or disabling condition for the purpose of this policy is defined as: an injury or illness which will be disabling for a predicted time of twenty (20) or more working days and is not related to a cosmetic surgery, or correctional surgery which in the opinion of medical experts can be performed during the summer months. The sick leave committee reserves the right to make exceptions to this policy in cases involving unusual circumstances. The applicant must have exhausted all accumulated sick leave. The applicant must demonstrate that a catastrophic or disabling condition exists. The grant application must be made within the contracted year that the condition occurs. The sick leave pool committee shall be the final authority on each grant. The applicant agrees to repay the Sick Pool under the guidelines stated in the Negotiated Agreement. If the applicant leaves the district, still owing days to the Sick Pool, the applicant agrees to a salary deduction at the daily rate during the year they leave the district for each day owed. If the applicant is disabled as evidenced by KPERS disability approval, reimbursement is not expected. Following for Use of Sick Leave Pool Committee: Do not Detach. Name Date Received by Committee Number of Sick Leave Days Accumulated at Beginning of School Year Date Sick Leave Days Exhausted Request Approved for Grant of Contract Days from the Sick Leave Pool. Request Denied: Reason Denied Date Approved or Denied by Committee Signature of Sick Leave Pool Committee Chairperson: Staff Evaluation Form School: Educator Name: Grade or Subject: Evaluator: Date: Time in: Time out: ○ Formal Evaluation/Observation Type of Evaluation: ○Summative Evaluation ...
Date Received. By: (Date) (Initials)
Date Received. 2. Hearing Held? Yes No Date:
Date Received. Notices shall be deemed effective upon the earlier of receipt, when delivered, or, if mailed, upon the date on the return receipt listed as delivered.
Date Received. In accordance with OAR 000-000-0000 and your fully executed performance agreement, an applicant of an energy conservation project with certified cost of $1 million or more must recertify the tax credit annually up to three years following the date of the issuance of the final certificate to receive the full value of the credit. To recertify the tax credit, ODOE must receive an Application for Recertification at least 60 days prior to the anniversary date of the issuance of the final certificate.
Date Received. Issued # Received Issued Losses / Adjustments Stock on Hand Remarks Quantity Rate Amount Quantity Rate Amount Quantity Rate Amount
Date Received. It is the Customer's responsibility to notify MGUC in writing if the term specified here changes. Customer (company) name: (print or type) Authorized customer signature: Date: Name of person signing: (print or type) Title (print or type) Address Street address City State Zip Code Phone: Fax: Send completed agreement to: Michigan Gas Utilities Corporation Attn: Xxxxxx XxXxxxxxx 000 X. Xxxxxxxxx Xx, Xxxxxx, XX 00000 Phone: (000) 000-0000 XXXxXxxxxxx@xxxxxxxxxxxxxxxxxxxx.xxx or Michigan Gas Utilities Corporation Attn: Xxxxx Xxxxxxx 000 Xxxxxxxx, Xxxxxx Xxxxxx, XX 00000 Phone: (000) 000-0000 xxxxxxxxx@xxxxxxxxxxxxxxxxxxxx.xxx
Date Received. AUTHORIZED SIGNER EXHIBIT "D" BORROWER INFORMATION STATEMENTS Borrower Information Statement
Date Received. Received By: --------------------- ------------------------
