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R C~V of <br /> amsey <br /> <br /> ADMINISTRATIVE SERVICES <br /> 15153 NowthenBoulevard N.W~ Phone:(612)427-1410 <br /> Ramsey, MN 55303 Fax: (612)427-5543 <br /> www. ci.ramsey.mn.us TDD: (612) 427-8537 <br /> <br />I II II II <br /> <br />I, , request vacation time donations from employees in <br /> (print name) <br /> <br />accordance with the City of Ramsey's Administrative Policy on Donation of Vacation Leave. <br /> <br /> Supporting medical data must be submitted with this request stating Physician's recommendation <br />on length of leave due to illness/injury. The medical data we collect from you will be used by the City <br />Administrator and Administrative Services Manager to evaluate your request for vacation leave donation with <br /> <br />I <br />I <br />I <br />I <br /> <br />regard to Ramsey's Administrative Policy on Donation of Vacation Leave. This information, which will be <br />maintained as part of your personnel record, is private and will not be shared with anyone other than as <br />specified above except with your informed consent. If you have any questions about the information we <br />ask you to provide, please contact the Administrative Services Manager. <br /> <br />Employee Signature Date <br /> <br /> I wish to have the reasons for my request shared with employees. I understand that this is private <br />data and can only be given with my release. <br /> <br /> ~ No, donor release the reason <br /> <br /> ~ Yes, pleasereleasethe reason for my request (optional) <br /> <br />I <br />I <br />I <br />I <br />I <br />I <br /> <br />The reason I request vacation leave donations is: <br /> <br />Administrative Services Manager <br /> <br />Med Info Rec'd <br /> <br />CityAdministrator <br /> <br />6/99 <br /> <br />I <br />I <br /> <br /> <br />