9.4.7.24

Appendix 13: Commission for the blind business enterprise program:

APPLICATION FOR LEAVE

Licensed Manager Name:___________________ Facility No.______

Date________

________________________________________________________________________________________

Type of Leave:

_____ ANNUAL START DATE______ ENDING DATE_____TOTAL HOURS_____

_____*SICK START DATE______ ENDING DATE_____TOTAL HOURS_____

TOTAL HOURS ____

________________________________________________________________________________________

____________________________ ____________________________

Licensed Mgr. Signature Date BEP Manager Signature Date

*Any request for five days or more of sick leave must be accompanied by a release form from the doctor.

[4/15/97; Recompiled 10/01/01]