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SICK LEAVE BANK REQUEST FORM - DOC by olliegoblue35

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									                           SICK LEAVE BANK REQUEST FORM
                               (Please Print or Write Legibly)


    DATE:

    NAME:

    ADDRESS:



    DEPARTMENT:

    LENGTH OF SERVICE:

    NATURE OF ILLNESS:




    PHYSICIANS NAME:

    PHYSICIANS ADDRESS:



    SIGNATURE:



READ AND SIGN MEDICAL RELEASE FORM BELOW AND SEND YOUR REQUEST TO
ANY ONE OF THE COMMITTEE MEMBERS LISTED:

   Kathleen DiCiaccio – Personnel
   MaryAlice Lally – Personnel
   Martha Pantanella - DPW


                 AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS

I hereby authorize the appointed Sick Bank Committee of the Somerville Municipal Employees
Association to be furnished with any information and facts regarding this injury/illness, including
reports and records, results of diagnosis, treatment and prognosis, estimates of disability, and to
furnish them copies of such reports. This information is to be used for the purpose of evaluating
and handling my request for additional sick time from the S.M.E.A. Unit B Sick Leave Bank and
for no other purpose, now or in the future.



Signature                                                    Date



        PLEASE SUBMIT ANY AND ALL DOCUMENTATION PERTAINING TO ILLNESS.

								
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