I, ___________________________________, apply for use of the Health Leave Bank effective as of ____________________. I understand that I must submit an initial doctor’s note certifying need for sick time. Once approved for use of the Health Leave Bank, I must submit a doctors note every 20 days to continue the use of the bank.

This condition is _________  pre existing  ______  not pre existing. (check one).

______________________________________                                     ____________________
Employee’s signature                                                                                 date

_____________________________________                                        ____________________
HR approval                                                                                               date

 College of DuPage
Office of Human Resources
425 Fawell Blvd.
Glen Ellyn, IL 60137
General Phone #(630) 942-2460
Job Opportunity Hotline # (630) 942-2796
cdhumres@cod.edu