Date of request: _______________________________________________________
Employee name: _______________________________________________________
Supervisor name: _______________________________________________________
Number of sick/personal days requested: ____________________________________
Reason for request for donated sick/personal time: ___________________________
_____________________________________________________________________
_____________________________________________________________________
______________________________________________________________________
______________________________________________________________________
I authorize [Company Name] to release the following information concerning my need to the employees in the company for the sole purpose of soliciting donations of sick/personal time.
______________________________________________________________________
______________________________________________________________________
Signature of employee: ____________________________ Date: __________________
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