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					Baruch College The City University of New York APPLICATION FOR SPECIAL LEAVE FOR CHILD CARE PURPOSES Instructions: Applicant completes form, attaches the child’s birth certificate, and forwards to department chair/unit head for signature. Chair/unit head forwards to school dean or appropriate vice president for signature and completed form is forwarded to the Human Resources Department. Name:________________________________ Social Security No.:________________ Rank/Title: ___________________________ Department:______________________ I hereby apply for a childcare leave of absence, for the period______________________ through____________________. I understand that the following conditions apply to this leave. 1. The leave is without pay and that if the period of leave is for one year or more it will not be credited towards salary movement within schedule. 2. The leave can be extended for a period that is not in excess of more than one year from the end of the original leave. 3. A childcare leave of absence does not cause a break in service towards tenure or towards a certificate of continuous employment. 4. Retirement System (TRS) tiers 1 and 2, must make a recommendation to that effect. The recommendation is only advisory to TRS and must be approved by the system for retirement credit to be granted. Employees of other TRS tiers and of other pension plans who are to leave without pay are not eligible for retirement credit while on leave. Date:_______________ Signature:____________________________________

Address during leave:_____________________________________________________ ______________________________________________________ NOTED: Date:___________________ Signed:__________________________________ (Department Chair/Unit Head) Signed:__________________________________ (School Dean) Signed:__________________________________ (Vice President) Signed:__________________________________ (Human Resources)

Date:___________________

Date:___________________

Date:___________________


				
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