Illness Application

**Bumper** · 04-29-2006

APPLICATION TO BE SICK

This form must be submitted at least 21 days before the date on which you wish your illness to begin.

NAME________________________EMPLOYEE NUMBER_________________

DEPARTMENT__________________POSITION______________ __________

NATURE OF ILLNESS___________________________________________ _

DATE ON WHICH YOU WISH ILLNESS TO COMMENCE___________________
(Application to suffer from pregnancy must be submitted twelve months prior and be accompanied by form # 36/248/9B) Consent of Husband / Wife____

HAVE YOU EVER APPLIED TO SUFFER FROM THIS ILLNESS BEFORE?_______

IF SO, GIVE DATES_________________________________

DO YOU WISH DISEASE TO BE MINOR / SEVERE / CRIPPLING / FATAL?_____

IF ILLNESS IS FATAL, DO YOU WISH IT TO BE CONSIDERED A PERMANENT DISABILITY? _____
(Applicants wishing to suffer a fatal illness should indicate at the bottom of this form whether they wish their co-workers and/or Board of Directors to be present at the funeral/cremation)

DO YOU WISH TO SUFFER THIS ILLNESS AT HOME / HOSPITAL / BANFF / HAWAII / ETC?_______

DO YOU WISH THIS ILLNESS TO BE CONTAGIOUS? ____________________

IF SO, APPROXIMATE THE NUMBER OF PEOPLE YOU WISH TO INFECT_____

HAVE YOU EVER BEEN REFUSED PERMISSION TO SUFFER AN ILLNESS?____

IF SO, GIVE DETAILS___________________________________________

DO YOU WISH YOUR SPOUSE TO BE INFORMED OF YOUR ILLNESS IF THEY CONTACT THE COMPANY REGARDING YOUR WHEREABOUTS? ____________

I, the undersigned, declare that to the best of my knowledge the answers given above are true and accurate.

SIGNED__________________________DATE______________ _________

Applicants are reminded that all applications will be considered on individual merit and that more than three applications per annum will be considered excessive, and not in the best interests of the company. UNDER NO CIRCUMSTANCES will any employee be permitted to suffer from more than one fatal illness.

babs31 · 05-22-2006

too cute! I work at a physicians office and on day three of sickness we have to go to a doctor! On day three we can then use our sick pay! Boy do I have alot of sick time accumulated

04-29-2006	#1 (permalink)
Bumper Class Clown Join Date: Feb 2003 Location: Winnipeg, Canada Posts: 9,516	Illness Application APPLICATION TO BE SICK This form must be submitted at least 21 days before the date on which you wish your illness to begin. NAME________________________EMPLOYEE NUMBER_________________ DEPARTMENT__________________POSITION______________ __________ NATURE OF ILLNESS___________________________________________ _ DATE ON WHICH YOU WISH ILLNESS TO COMMENCE___________________ (Application to suffer from pregnancy must be submitted twelve months prior and be accompanied by form # 36/248/9B) Consent of Husband / Wife____ HAVE YOU EVER APPLIED TO SUFFER FROM THIS ILLNESS BEFORE?_______ IF SO, GIVE DATES_________________________________ DO YOU WISH DISEASE TO BE MINOR / SEVERE / CRIPPLING / FATAL?_____ IF ILLNESS IS FATAL, DO YOU WISH IT TO BE CONSIDERED A PERMANENT DISABILITY? _____ (Applicants wishing to suffer a fatal illness should indicate at the bottom of this form whether they wish their co-workers and/or Board of Directors to be present at the funeral/cremation) DO YOU WISH TO SUFFER THIS ILLNESS AT HOME / HOSPITAL / BANFF / HAWAII / ETC?_______ DO YOU WISH THIS ILLNESS TO BE CONTAGIOUS? ____________________ IF SO, APPROXIMATE THE NUMBER OF PEOPLE YOU WISH TO INFECT_____ HAVE YOU EVER BEEN REFUSED PERMISSION TO SUFFER AN ILLNESS?____ IF SO, GIVE DETAILS___________________________________________ DO YOU WISH YOUR SPOUSE TO BE INFORMED OF YOUR ILLNESS IF THEY CONTACT THE COMPANY REGARDING YOUR WHEREABOUTS? ____________ I, the undersigned, declare that to the best of my knowledge the answers given above are true and accurate. SIGNED__________________________DATE______________ _________ Applicants are reminded that all applications will be considered on individual merit and that more than three applications per annum will be considered excessive, and not in the best interests of the company. UNDER NO CIRCUMSTANCES will any employee be permitted to suffer from more than one fatal illness.

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05-22-2006	#2 (permalink)
babs31 life=playa Join Date: Oct 2004 Location: south of Green Bay Posts: 849	too cute! I work at a physicians office and on day three of sickness we have to go to a doctor! On day three we can then use our sick pay! Boy do I have alot of sick time accumulated

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